Connection supplemental articles and policies - January 2000

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Connection - January 2009 (pdf, 171 KB)

Supplemental articles

• FCHP’s MCC and other plan design changes for 2009
• Retail specialty drugs to be dispensed at CVS Caremark Specialty
• New doc finder at fchp.org
• Fallon Senior Plan: 2009 Group Medicare product update
• FCHP adds MinuteClinic to provider network
• Quit-smoking collaboration with FCHP
• Important links to information about care
• Formulary updates – commercial
• Modifier -26 and clinical laboratory and pathology services

Policies and forms

The following policy is new:

• Facility Bill/Charge Audit Policy

The following policies have been reviewed and changes are indicated on each policy:

• Anesthesia Payment Policy
• Emergency Department Payment Policy
• Evaluation and Management Payment Policy
• Global Surgical Payment Policy
• Inpatient Medical Review and Payment Policy
• Medical Supplies and Surgical Dressings Payment Policy
• Non-covered Services Payment Policy
• Procedure Code Review Payment Policy

The following policy has been retired:

FCHP’s MCC and other plan design changes for January 1

Minimum creditable coverage
Fallon Community Health Plan has taken steps to ensure that all of our FCHP Direct Care, FCHP Select Care and Fallon Preferred Care group plans meet minimum creditable coverage as required by health care reform. As of January 1, 2009, we will discontinue for all small groups and most individuals any existing plans that don’t have prescription drug coverage. Large groups may request them on a non-standard basis.

To replace these plans, FCHP is introducing new plan design options with a prescription drug coverage benefit of $25/$100/$100. These plans mirror the non-prescription drug coverage plans in every other way. The higher Tier-2 and Tier-3 prescription drug copayment amounts allow members to meet required coverage at no additional premium cost. Existing FCHP members who currently don’t have prescription drug coverage will be switched automatically to one of these corresponding new plans with drug coverage for January 1.

High-deductible plan changes
There are other changes for the New Year as well. As of January 1, the out-of-pocket maximums for several of our Fallon Preferred Care high-deductible plans will increase upon anniversary date renewals. Embedded deductibles and embedded out-of-pocket maximums (what any single family member is responsible for) on FCHP’s qualified high deductible plan design options also will change on January 1 due to 2009 IRS guidelines.

If you have any questions about these changes, please contact Provider Relations at 1-866-ASK-FCHP (1-866-275-3247), press 4.

Retail specialty drugs to be dispensed at CVS Caremark Specialty

Effective March 1, 2009, Fallon Community Health Plan will exclusively partner with CVS Caremark Specialty Pharmacy for all specialty drugs dispensed through the retail benefit. This means that members using specialty drugs through the pharmacy benefit will be required to use one of the following pharmacies:

• CVS Caremark Specialty Pharmacy - Mail order 1-877-287-1234
• CarePlus CVS/pharmacy  (formally PharmaCare pharmacies located in Fallon Clinics as well as PharmaCare Specialty Pharmacies located in Boston and Providence, RI)

No changes will be made to specialty drugs that are billed through the medical benefit. The change is only for retail benefits. Separate communication will be made to affected members and their prescribing physicians notifying them of this change.

The new benefit will allow members to fill the initial script at any participating pharmacy and then all refills must be obtained through the CVS Caremark pharmacies listed above. The following medical conditions or treatments may be relevant to this change:

• Cancer
• Cystic fibrosis
• Growth hormone
• Hematopoetics
• Hepatitis C
• Hormonal therapies
• Infertility
• Macular degeneration
• Multiple sclerosis
• Osteoarthritis
• Osteoporosis
• Psoriasis
• Pulmonary arterial hypertension
• Rheumatoid arthritis

New doc finder at fchp.org

At the end of October, Fallon Community Health Plan introduced a new and improved “Find a doctor” tool on its Web site that provides FCHP customers with a more effective and efficient process to search for providers.

We did considerable behind-the-scenes work to maximize the accuracy of our data and how it is searched. We also optimized the tool’s visual layout, content and functionality to increase ease-of-use for our Web site visitors.

The “Find a doctor” tool may be used to find primary care physicians, dentists, orthodontists, oral surgeons, eye doctors, specialists and behavioral health providers. It is not used for tertiary providers with highly specialized services, hospitals, rehab centers, labs and other medical facilities.

Users of the “Find a doctor” tool are able to search by provider’s name; network; state; distance from a ZIP code; specialty; provider’s gender; and provider’s language. You can check it out at fchp.org/FindPhysician/.

Fallon Senior Plan: 2009 Group Medicare product update

We’re pleased to announce that premiums and benefits for our 2009 Group Medicare options with Fallon Senior Plan™ have no major changes. We feel it’s important to continue to offer affordable options with comprehensive benefits.
 
We’ve made a sizeable increase in the Group Medicare HMO service area for our employer and union group customers. Like the Fallon Senior Plan HMO product offered to individuals, the Medicare Group service area has expanded into Hampden County, effective January 1, 2009.

In addition, this plan is available to FSP Group Medicare members that live in some of the 2008 HMO service area’s border towns. These members still will need to receive their care from our Fallon Senior Plan HMO provider network for service, but this expansion allows employers to provide coverage to more of their retirees.

Also, we’ve added a new U.S. travel benefit for Fallon Senior Plan HMO products, effective January 1, 2009. There is unlimited coverage, and no referrals or authorizations required, for certain medical services received from a provider that accepts Medicare when the member is traveling outside of the northeastern states. This benefit also is available to individual Fallon Senior Plan HMO members. You can find more details about this benefit in the November issue of Connection.

And of course, the Group Medicare plans come with those great “healthy extras” such as the eyewear purchase benefit of $150 every 24 months and a hearing aid purchase benefit of $500 every 36 months. Now, our Group Medicare members also may use their $150 eyewear benefit for either glasses or contact lenses. Previously, the benefit was applicable to eye glasses only.

Fallon Senior Plan Group members continue to receive many more benefits than traditional Medicare, including health and wellness education, disease care services, dental care and chiropractic services, the SilverSneakers® Fitness Program and Weight Watchers®. Members of a Fallon Senior Plan Group Medicare plan should contact their benefits administrator to learn more about their 2009 plan coverage and benefits.

For more information about our 2009 plan benefits for employer and union groups, please contact Provider Services at 1-866-ASK-FCHP, press 4.

SilverSneakers® is a registered trademark of Healthways.
Weight Watchers® is a registered trademark of Weight Watchers International, Inc.

FCHP adds MinuteClinic to provider network

Fallon Community Health Plan’s commercial plan members* are now covered for treatment received at new MinuteClinic® locations opening in the state. MinuteClinic, Inc., has been a subsidiary of CVS Caremark Corporation since 2006. 

These “mini-clinics”—also known as limited service providers—are a new phenomenon for Massachusetts. The first to open in the Commonwealth, CVS’ for-profit MinuteClinic has more than 525 locations in 27 states. Beginning in mid September, a MinuteClinic has opened in such CVS/pharmacy locations as Beverly, Bridgewater, Brockton, Danvers, Medway, Taunton, Tewksbury and Westford—and will eventually total about 100 clinics in communities across the state. 

Access and convenience for minor ailments
MinuteClinic certified nurse practitioners and physician assistants are trained to diagnose, treat and write prescriptions for certain common ailments—such as strep throat, routine ear, eye and sinus infections, minor burns or rashes—and offer routine vaccinations. A collaborating physician is on call whenever the clinic is seeing patients. The MinuteClinic locations are open seven days a week and never require an appointment or referral. FCHP members must show their ID card at the visit and will be responsible for their usual PCP office visit copayment.

They do not see patients under age 2. When patients have conditions outside the clinic’s scope, MinuteClinic refers them to their family physician or nearest urgent care or emergency room. CVS/pharmacy MinuteClinic health care centers are not affiliated with any hospitals and don’t provide emergency care.

Safeguards in place for quality care
While giving our members more options to receive quick access or after-hours care for minor conditions, these limited-service clinics fill a niche that may help address the PCP shortage in our state and reduce costs incurred with inappropriate use of emergency room visits for minor ailments. FCHP continues to encourage our members to maintain their important relationship with their primary care doctor. To promote continuity of care, CVS’ MinuteClinic generates an electronic medical record for each visit that is automatically sent to the PCP upon the member’s consent.  

Before entering the market, the CVS clinics underwent extensive review by Massachusetts regulators, who put a number of safeguards in place to ensure that the limited service clinics would not sacrifice quality in the name of expediency. The clinics already followed nationally established clinical practice guidelines and are approved by The Joint Commission, the national evaluation and certifying agency for health care organizations. 

* Members of FCHP MassHealth and Fallon Senior Plan are not covered for visits to mini-clinics.

Quit-smoking collaboration with FCHP

It’s been more than four decades after the 1964 U.S. Surgeon General Report on the health consequences of smoking. Yet, smoking still remains the leading cause of preventable death and disease. Each year, approximately 440,000 Americans die of smoking-related illnesses and an estimated 50,000 people who don’t smoke die of illnesses related to secondhand smoke. But, the good news is that over 3 million Americans are successfully quitting each year.

As the calendar changes and a new year begins, many people take the opportunity to bring some change into their lives. Changing their smoking habit can be the beginning of some drastic and positive changes in their health and well-being.

Fallon Community Health Plan offers a highly successful, personalized tobacco cessation program to all members. Quit to Win provides free support groups, facilitated by qualified experts, in locations throughout Central Massachusetts. Also, Quit to Win is expanding its help by offering free individual telephone support. Any Fallon Clinic provider can refer patients into the program. As an additional member-only benefit, nicotine replacement patches and/or gum are available to FCHP members at a significantly reduced cost (or free for some plans!)

Contact FCHP’s Quit to Win program: 1-888-807-2908 or QuitToWin@fchp.org
                                                                                                                                   
Here are a few other ways you can help:

• Start today to ask each of your patients who smokes, “Do you want help with quitting smoking today?”
  
• Order posters to display and/or or flyers to distribute from Quit to Win:1-888-807-2908 or QuitToWin@fchp.org
  
• Inform your employees that they may be able to get coverage for smoking cessation counseling and medications through their insurer.
• Organize a Grand Rounds or lunch-time seminar on effective smoking cessation treatment. Quit to Win would be glad to provide a qualified speaker.
  

Important links to information about care

We hope you’ll take this time to visit our Web site, fchp.org, to learn how we work with you and our members to ensure the quality and safety of clinical care. If you would like to receive a copy of this information, please call our Provider Relations Department at 1-866-ASK-FCHP (1-866-275-3247), press 4.

• Clinical criteria for utilization care services: Fallon Community Health Plan uses national, evidence-based criteria that are reviewed annually by a committee of health plan and community-based physicians to determine the medical appropriateness of selected services requested by physicians. These criteria are approved as being consistent with generally accepted standards of medical practice, including prudent layperson standards for emergency room care. Criteria are available on the FCHP Web site at fchp.org/providers/resources/medpolicies.aspx or as a paper copy upon request.
  
  
• Learn more about our quality programs: FCHP is proud of its long history of quality accomplishments, including our “Excellent” accreditation from the National Committee for Quality Assurance. A detailed description of our quality program, goals and outcomes is available through at fchp.org/about/quality.aspx.
  
  We also welcome suggestions from our physicians about specific goals or projects that may further improve the quality of care and service available through our health plan projects.
  
  
• Know our members’ rights: FCHP members have the right to receive information about an illness, the course of treatment and prospects for recovery in terms that they can understand. They have the right to actively participate in decisions regarding their own health and treatment options, including the right to refuse treatment. For a complete list of FCHP members’ rights and responsibilities, visit fchp.org/members/resources/rights.apex.

Formulary updates

Fallon Community Health Plan often makes changes to its formularies, including changing prior authorization requirements and adding new medications. Please note the following changes to our commercial plan formulary.

Commercial plan formulary

Additions
Actonel® (risedronate) 150 mg                       Tier 3, QLL 1 per 30 days
Durezol® (difluprednate) Oph Emul                Tier 3
Glumetza® (metformin 24H rel) 1000 mg       Tier 3
Kuvan® (sapropterin)                                      Tier 3, PA required
Pristiq® (desvenlafaxine)                                 Tier 3, PA required, QLL 30 per 30 days
Prezista® (darunavir) 600 mg tab                   Tier 3
Requip XL®                                                      Tier 3
Rotarix® (rotavirus vaccine)                            Medical benefit
Veregen® (sinecatechine)                               Tier 3, PA required
Xyzal® (levocetirizine) Soln                             Tier 3, PA required, QLL 150 per 30 days

New to Market Policy**
Aczone® (dapsone)
Alvesco® (ciclesonide)
Entereg® (alvimopan)
Hycamtin® (topotecan, oral)
Relistor® (methylnaltrexone)
Sancuso® (granisetron, topical)
Stavzor® (valproic acid, DR)

** FCHP’s New to Market Policy was enacted to ensure patient safety and to allow for adequate time for the development, review and approval of clinical criteria. When a new medication first becomes available, it will fall under this policy and be excluded from coverage. A process is in place that allows for the quick review of provider requests for non-covered pharmaceuticals. •

Modifier -26 for clinical laboratory and pathology services

Modifier -26 is used to describe and represent the professional component portion of a procedure or service. There are codes that aptly identify the professional component of clinical laboratory procedures, so for this reason it is incorrect to report modifier -26 along with these codes. Some examples of this are 81003, 81050, 82310, 82374, 82565, 82947, 84520 and 85027. Use of the -26 modifier with these codes will result in a claim line rejection from Fallon Community Health Plan.

Following is a list of clinical laboratory and pathology services for which modifier -26 is appropriate