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Connection supplemental articles and policies - November 2010

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Connection - November 2010

Supplemental articles

FCHP adds Medicare Supplement product
Summit ElderCare: referrals and authorizations
MassHealth: PCPs continue to increase rate of behavioral health screenings
Formulary updates

Payment policies

Revised policies – effective January 1, 2011
The following polices have been updated; details about the changes are indicated on the policies:

Assistant Surgeon Payment Policy : Clarified industry standard sources for allowance of surgical assist.
Clinical Trials Payment Policy : Reflected payment to member for Medicare coinsurance.
Durable Medical Equipment Capped Rental Payment Policy : Changed name to Durable Medical Equipment and added language to reflect policy updates regarding capped rental vs. purchase vs. rent-to-own.
Evaluation and Management Payment Policy : Added discussion of limitations on reimbursement for certain codes submitted with evaluation and management codes; removed discussion of medical record documentation requirements related to consultation codes.
Infertility/Assisted Reproductive Technology (ART) Services Payment Policy : Updated to reflect changes to prior authorization and billing requirements.
Palliative Care Consultation Payment Policy : Removed the consultation code range from the policy.
Special Services, Procedures and Reports Payment Policy : Removed the consultation code range from the policy.

Everyday affairs

FCHP adds Medicare Supplement product

More Medicare options
Fallon Community Health Plan is introducing this fall a Medicare Supplement (Medigap) insurance option for individual consumers. Our Medicare Supplement plans further diversify our non-group senior-product portfolio, which includes Medicare Advantage HMO plans, NaviCare HMO SNP and more.

Fallon Senior Plan’s two Medicare Supplement plans, “Core” and “1”, will be attractive to individuals who are enrolled in Original Medicare and chose not to enroll in a Medicare Advantage HMO plan. Members pay a higher premium than our very popular Medicare Advantage HMO plans. However, they pay little to nothing on health care expenses, such as deductibles, coinsurance and other gaps in Original Medicare coverage that remain after Medicare has covered its portion of the costs.

More freedom
Our two Medicare supplement plans have different levels of coverage and premiums. With Medicare Supplement plans, there are no networks, members do not have to designate a PCP and they can see any Medicare provider without referrals. For more details about this product, call our Provider Relations Department at 1-866-275-3247, prompt 4—and look for an updated article in the January issue of Connection.

More flexibility
Fallon Community Health Plan has a long history and excellent reputation for serving Medicare beneficiaries in Massachusetts. Our new Medicare Supplement plans are yet another way we offer more quality, flexibility and security to this population.

Summit ElderCare: referrals and authorizations

Summit ElderCare^® is FCHP’s Program of All-Inclusive Care for the Elderly (PACE). This innovative program enables frail elders to remain living in the community as an alternative to nursing home placement. It provides comprehensive coverage for approved services with no participant copayments or deductibles.

If a Summit ElderCare participant is referred to your office for nonemergency services, please ensure that your services have been authorized in advance by Summit ElderCare. In most instances, you should have the referral information and authorization in advance of the visit.

All program participants have a Summit ElderCare member identification card. This card includes the numbers you may call for authorization or additional information regarding participant needs. If you have a question, our provider staff can access a participant’s comprehensive electronic medical record and care plan on a 24/7 basis to enhance coordination of care and services.

Program staff is available Monday through Friday from 8:00 a.m. to 5:00 p.m.—and there are always Summit ElderCare providers on-call to assist you and our participants on nights and weekends.

To learn more about this program, visit the Summit ElderCare Web site at www.summiteldercare.org, or view the Summit ElderCare section under “FCHP Products” in our Provider Manual.

For our MassHealth providers

PCPs continue to increase rate of behavioral health screenings

The use of standardized behavioral health screening tools for children and youth continued to increase throughout 2009. During the first quarter of 2009, 50% of all children and youth under 21 received behavioral health screenings during well-care visits. By the fourth quarter of 2009, this number grew to 58%. For 9.6% of the children and youth screened in the first quarter, providers used a billing modifier indicating that the child had a possible behavioral health need. For the fourth quarter, this figure was 8%.

However, the data in Table 1 and Table 2 show considerable variation in screening rates by age and geographic region.

As seen in Table 1, close to 70% of all children ages 3 through 12 were receiving standardized behavioral health screening during well-care visits by the end of CY 2009.

Table 1 Behavioral health screening by age group (Oct – Dec 2009)

	Total well-care visits	Total screens	% visits with screens	% Behavioral health need identified*
<6 mos	23,116	7,967	34%	1%
6 mos to 2 yrs	32,548	20,922	63%	5%
3 yrs to 6 yrs	18,248	12,766	68%	10%
7 yrs to 12 yrs	21,236	15,428	70%	11%
13 yrs to 17 yrs	16,630	11.033	64%	11%
18 yrs to 20 yrs	4,660	1,416	29%	11%

* "Behavioral health need identified” means the provider administering the screening tool, in his or her professional judgment, identified a child with a potential behavioral health services need.

These data indicate a low rate of screening for babies under 6 months of age. The low screening rate may be accounted for by the lack of appropriate screening tools and clinicians’ questions about the utility of screening in this age group.

A similar low rate of screening appears in the 18 to 20 year age group. Here, PCPs may not realize these members are covered by EPSDT program schedules. It also may be that young adults are seeing adult providers who are not as aware of the behavioral health screening requirement.

The data also show variation in screening rates by geographic region, as seen in Table 2.

Table 2 Behavioral health screening by region (Oct – Dec 2009)

	Total well-care visits	Total screens	% Visits with screens	% Behavioral health need identified
Boston region	26,392	13,323	48%	8%
Central region	8,436	4,895	56%	10%
Metro West region	13,524	6,911	50%	5%
Northeast region	18,830	10,524	54%	6%
Southeast region	24,062	16,084	65%	6%
Western region	21,814	15,750	70%	11%

MassHealth and its contracted Managed Care Organizations (MCOs) are looking further into these findings in the data regarding screening rates by age and geography.

Improving behavioral health screening
Higher rates of behavioral health screening are possible. By sending reminders for and scheduling well-child visits for children and youth, PCPs will have the opportunity to both improve the proportion of children screened at the time of their well-child visit and increase their well-child visits as well. If you have a story about a success or challenge experienced in improving behavioral health screening in your practice, MassHealth would like to hear from you. Please send an e-mail to CBHI@state.ma.us.

Meeting the MassHealth requirement
MassHealth and its contracted MCOs require PCPs to offer behavioral health screenings at every well-child visit for children and youth under 21, using MassHealth-approved standardized screening tools and a billing modifier to indicate in the clinician’s judgment whether behavioral services are needed.

If you are a MassHealth MCO PCP and have not implemented behavioral health screening in your practice, training resources are available on the Children’s Behavioral Health Initiative (CBHI) Web site, mass.gov/masshealth/childbehavioralhealth, under “Training for Providers.” In the section, “Using Behavioral-Health Screening Tools for Children under the Age of 21 in the Primary-Care Setting,” you will find helpful information about the requirement, MassHealth- approved screening tools, suggestions for implementing standardized behavioral health screening in your practice and other useful information.

Script alert

Formulary updates

Fallon Community Health Plan often makes changes to its formularies, including changing prior authorization requirements and adding new medications. Below are the latest changes to our commercial plan and Part D formularies.

Commercial plan formulary

Additions

Anaztrozole tab	Tier 1
Azelastine Soln 0.05%	Tier 1
Dulera (formoterol/mometasone)	Tier 3
Gianvi (drosperenone/e estradiol)	Tier 1
Natazia (estradiol and estradiol/dienogest)	Tier 3
Pancreaze	Tier 3
Rivastigmine Cap	Tier 1
Tamsulosin Cap	Tier 1

Changes

Tretinoin Topical Acne Products	PA Required if > 25 years of age
Crestor	Step added. Prior use of simvastatin AND Lipitor
Antara	Step added. Prior use of generic fenofibrate and gemfibrozil
Tricor	Step added. Prior use of generic fenofibrate and gemfibrozil
Trilipix	Step added. Prior use of generic fenofibrate and gemfibrozil
ProAir HFA	QL added. 2 canisters per month
Ventolin HFA	QL added. 2 canisters per month
Proventil HFA	QL added. 2 canisters per month
Advair HFA	QL added. 1 canister per month
Advair Diskus	QL added. 60 per month
Flovent Diskus	QL added. 60 per month
Flovent HFA	QL added. 1 canister per month
Pulmicort Inhaler	QL added. 1 canister per month
Beconase AQ	Step added. Prior use of generic flunisolide and fluticasone
Flonase	Step added. Prior use of generic flunisolide and fluticasone
Nasacort AQ	Step added. Prior use of generic flunisolide and fluticasone
Omnaris	Step added. Prior use of generic flunisolide and fluticasone
Rhinocort AQ	Step added. Prior use of generic flunisolide and fluticasone
Veramyst	Step added. Prior use of generic flunisolide and fluticasone

New-to-Market Policy*
Iprivask (desirudin)
Rosula Aerosol (sulfacetamide/sulfur)
Silenor (doxepin [sleep])
Tribenzor (amlodipine/HCTZ/olmesartan)
Xerese (acyclovir/hydrocortisone)

* 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.

Part D formulary update

Drug description	BvG	Status
ACTOPLUS MET XR 1000MG; 15MG TB24	Brand	Added as Tier 2
ACTOPLUS MET XR 1000MG; 30MG TB24	Brand	Added as Tier 2
ADAPALENE CREA 0.1%	Generic	Added as Tier 1
ADAPALENE GEL 0.1%	Generic	Added as Tier 1
ANASTROZOLE TABS 1MG	Generic	Added as Tier 1
AZELASTINE HCL 137MCG/SPRAY SOLN	Generic	Added as Tier 1
LEVETIRACETAM SOLN 500MG/5ML	Generic	Added as Tier 1, PA required
METHAMPHETAMINE HCL 5MG TABS	Generic	Added as Tier 1
NORVIR 100MG TABS	Brand	Added as Tier 2
PANCREAZE 17500U; 4200U; 10000U CPEP	Brand	Added as Tier 3
PANCREAZE 43750U; 10500U; 25000U CPEP	Brand	Added as Tier 3
PANCREAZE 61000U; 21000U; 37000U CPEP	Brand	Added as Tier 3
PANCREAZE 70000U; 16800U; 40000U CPEP	Brand	Added as Tier 3
TRANDOLAPRIL/VERAPAMIL HCL 2MG; 180MG TBCR	Generic	Added as Tier 1
TRANDOLAPRIL/VERAPAMIL HCL 2MG; 240MG TBCR	Generic	Added as Tier 1
TRANDOLAPRIL/VERAPAMIL HCL 4MG; 240MG TBCR	Generic	Added as Tier 1
VENLAFAXINE HCL ER CP24 37.5MG	Generic	Added as Tier 1
VENLAFAXINE HCL ER CP24 75MG	Generic	Added as Tier 1
VENLAFAXINE HCL ER CP24 150MG	Generic	Added as Tier 1
VIMPAT 10MG/ML SOLN	Brand	Added as Tier 3, PA required