Connection supplemental articles and policies - May 2006

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Connection - May 2006 (pdf, 216 KB)

supplemental articles

• fchp support for high-risk pregnancies
• masshealth restores dental coverage
• new hedis^® measures introduced
• formulary updates: commercial and medicare

policies and forms

• Ambulance service payment policy (pdf, 69 KB)
• Anesthesia payment policy (pdf, 57 KB)
• Clinical trials payment policy (pdf, 60 KB)
• Counseling and/or risk factor reduction intervention services payment policy (pdf, 37 KB)
• Eye examinations and refraction payment policy (pdf, 49 KB)
• Home-grown codes payment policy (pdf, 40 KB)
• Neonatal and pediatric critical care services payment policy (pdf, 41 KB)
• Team conferences and telephone consults service payment policy (pdf, 35 KB)
• Transplant payment policy (pdf, 62 KB)

every day affairs

Fallon Community Health Plan’s new obstetrical program, Special Deliveries, offers support to pregnant women at risk for complications—including, but not limited to, premature delivery. The practical and emotional costs of premature delivery are immense. Our goal is to help these mothers and their babies have the healthiest pregnancy possible and to help mothers deliver closer to full term.

Between 1993 and 2003, the rate of infants born preterm in Massachusetts increased more than 37%.These infants are at risk for lifelong problems, such as cerebral palsy, mental retardation, chronic lung disease, hearing loss and blindness. An infant born at 35 weeks incurs expenses that are greater than 10 times that of an infant born at 38 weeks. The estimated cost to employers’ health plans is $4.7 billion.

FCHP’s high-risk obstetrical program provides case management support throughout the pregnancy. We also offer education, home health services and identification of community resources to support or supplement care.

Members who would benefit from Special Deliveries include, but are not limited to, women with:

• hyperemesis
• current or history of preterm labor and/or delivery
• chronic medical conditions, such as diabetes, coronary artery disease and autoimmune disorders
• premature rupture of membranes after 16 weeks gestation
• vaginal bleeding
• pregnancy-induced hypertension
• current or previous history of preeclampsia

We also would work with members who present with socioeconomic challenges.

To refer a member to our Special Deliveries program, please fax either (1) the Outpatient Care Services referral form  (2) a completed Massachusetts Health Quality Partners Obstetrical Risk Assessment tool; or (3) the member’s prenatal record.

For additional information about this program, please contact Susan Legacy, R.N., Manager, Disease Care Services, at 800-333-2535, ext. 69490.

masshealth restores dental coverage

• Emergency care visits
• Diagnostic services, including oral evaluation (comprehensive and periodic)
• Radiographs
• Preventive services, including prophylaxis, periodontal scaling and root planing, and gingivectomy or gingivoplasty
• Restorative services, including amalgam restorations, composite resin restorations, reinforcing pins, and crowns for anterior teeth
• Endodontic services, including root canals for anterior teeth
• Prosthodontic services, including full and partial dentures
• Exodontic services (extractions)
• Oral surgery

For more information about these services, please contact MassHealth Customer Service at 800-841-2900 or the FCHP Customer Service Department at 800-868-5200.

new hedis^® measures introduced

We want to make you aware of six new measures for HEDIS^® in 2006. HEDIS is a set of standardized measures that allows comparisons between health plans on quality, access, patient satisfaction, membership, utilization and more. HEDIS was developed by employers, HMOs and the National Committee for Quality Assurance.

Below is a summary of the six HEDIS measures.

1. Inappropriate antibiotic treatment for adults with acute bronchitis
   This looks at the percentage of healthy adults ages 18 to 64 who were dispensed a prescription for an antibiotic on or within three days of episode date. It is a misuse measure—a lower rate is better.
2. Use of spirometry testing in the assessment and diagnosis of COPD
   This considers the percentage of members 40 years and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.
3. Follow-up care for children prescribed ADHD medication
   This measure has two components:
   1. The percentage of members ages 6 to 12 with an ambulatory prescription for an ADHD medication who had one follow-up visit with a prescribing practitioner within the 30-day initiation phase
   2. The percentage of members ages 6 to 12 with an ambulatory prescription for an ADHD medication who remained on the medication for at least 210 days and had at least two additional follow-up visits with a practitioner within nine months after the initiation phase ends
4. Disease-modifying anti-rheumatic drug therapy in rheumatoid arthritis
   This measure assesses whether patients diagnosed with rheumatoid arthritis have had at least one ambulatory prescription dispensed for a disease-modifying anti-rheumatic drug.
5. Annual monitoring for patients on persistent medications
   This measure assesses the percentage of members 18 and older on persistent medications (at least 180 days) who received annual monitoring for the drugs of interest. (Please see Table A below.)

   The drugs of interest in this measure are:

   • ACE inhibitors/ARBs
   • Digoxin
   • Diuretics
   • Anticonvulsants
   • Statins

6.  Drugs to be avoided in the elderly
There are two components to this measure, on which lower scores are better:

1. This measure assesses the extent to which elderly members 65 years of age and older have had some exposure to one potentially harmful drug.
2. This measure also assesses whether elderly members have been exposed to two or more harmful drugs. A lower rate is better. (Please see Table B, from the NCQA, below.)

If you would like more detailed information regarding these measures (including background, relevance, scientific soundness and feasibility), please contact Christine Smith in the FCHP Quality and Health Services Department at 866-ASK-FCHP, ext. 69101, or e-mail Christine at christine.smith@fchp.org.

Table B
Drugs to be avoided in the elderly*

* Chart source: The National Committee for Quality Assurance, HEDIS® 2006 Volume 2: Technical Specifications, p. 171. © National Committee for Quality Assurance 2005. Reprinted by permission.

** FCHP note: The antipsychotic medication mesoridazine (Serentil) and the amphetamine/ stimulant medication Pemoline (Cylert) are no longer on the market. Also, barbiturates are a class of drugs not covered by Medicare Part D.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). NCQA is an independent, not-for-profit organization dedicated to measuring the quality of America’s health care.

script alert

formulary updates

Fallon Community Health Plan has made several changes to its formularies, including changing prior authorization requirements and adding new medications. Please see the list of changes to our commercial plan and our Medicare Part D formularies below.

* FCHP’s Moratorium 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 noncovered pharmaceuticals.

medicare part d formulary