February 2024 Newsletter

Heart-Felt Gratitude

February’s a month where hearts take center stage. Valentine’s Day last week brought heart-shaped candy, cards and decorations. On a more serious note, it’s also American Heart Month, a time to raise awareness of cardiovascular health. For us, February’s a month – like all 11 others – where our hearts are full of thanks for all you do to take care of our members. We extend our deepest gratitude for your skills, knowledge, dedication and partnership.

The Two-Midnight Rule:

Important Information About CMS Guidelines and Inpatient Admissions

Note: This article only applies to our Medicare Advantage plans.

A new rule from the Centers for Medicare & Medicaid Services (CMS), effective January 1, 2024, outlined important information about admission for inpatient care for patients with Medicare Advantage.

The new rule centers around the long-standing “two-midnight rule” that defines when inpatient admissions are appropriate for payment from us, the health plan.

Please see the important document linked below to understand specifically:

• How we’ll continue to review inpatient admissions for medical necessity.
• The conditions that require us, the health plan, to cover inpatient admissions.
• Steps you need to take when documenting and evaluating in the EMR.
• How to find resources and help, if you have any questions or need additional clarity or support.

Find our full document and guidance here: CMS Guidelines and Inpatient Admissions. And please reach out if you have any questions.

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Help us move the needle.

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

It’s CAHPS^® survey time.

It’s that time again. From February 28 through June 1, Medicare is running its Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. This annual survey collects feedback from your patients (who have Medicare) about their experiences with their health and drug plans, as well as with the healthcare system in general.

What you do matters – so it’s important you know what CAHPS is and the impact you have on the survey. We’ve put together two valuable resources for you. Here you’ll find key information on what exactly CAHPS is; specific things the survey measures; sample survey questions; what parts of the survey you and your staff have an impact on; and tips and an entire toolkit to help your team improve patient experience and satisfaction.

• CAHPS PowerPoint resource.
• CAHPS toolkit for providers.

Surgeon General’s Call to Action: Help control hypertension.

Did you know that nearly half of all adults in the U.S. have hypertension? Or that 3 in 4 of these adults do not have their high blood pressure under control? Hypertension is a preventable risk factor for both heart disease and stroke, and it’s time we all take action.

The U.S. surgeon general is asking for our help – by leading a “call to action” against hypertension. As providers, your role is key as you care for, educate and monitor your patients. The surgeon general’s plan calls for averting the negative effects of high blood pressure by identifying, implementing, adapting and expanding evidence-based interventions.

The main goals and strategies of the “call to action” are highlighted in the graphic below. Think about how you can put these into action:

The surgeon general’s initiative also:

• Calls attention to the fact that where people are born, live, learn, work, play and worship often directly impacts their health, along with their age and other factors.
• Focuses on tangible, specific interventions that can be replicated and adapted to fit the unique needs of your patients and community.

Let’s all commit to this important “call to action” against the harms of hypertension. To find information, specific strategies for providers, toolkits and much more, visit here.

There’s still time: Remind your patients to get their flu shots.

February is still flu season, and it’s important as ever that people are vaccinated against influenza. We hope the majority of your patients have already gotten their flu shots this season, but for those who haven’t, your voice is key. According to the CDC, recommendations – and even simple reminders – from their trusted providers are a critical factor in whether many adults get vaccines for themselves and their families.

With this in mind, the CDC is continuing its vital SHARE campaign – meant to help providers do all they can to encourage their patients to get their yearly flu shot. Here are the basics, quoted from their campaign:

• S – Share the reasons why an influenza vaccine is right for the patient given their age, health status, lifestyle, occupation or other risk factors.
• H – Highlight positive experiences with influenza vaccines (personal or in your practice), as appropriate, to reinforce the benefits and strengthen confidence in influenza vaccination.
• A – Address patient questions and any concerns about influenza vaccines, including side effects, safety and vaccine effectiveness, in plain and understandable language. Acknowledge that while people who get an influenza vaccine may still get sick, there are studies that show that illness may be less severe.
• R – Remind patients that influenza vaccines help protect them and their loved ones from serious influenza illness and complications that can result in hospitalization or even death for some people.
• E – Explain the potential costs of getting influenza, including potential serious health effects for the patient, time lost (such as missing work or family obligations), financial costs and potentially spreading influenza to more vulnerable family or friends.

Each patient’s different, and you know them best. Consider the best approach that’ll let them know just how important the flu vaccine is and why they and their families should get it. With your help, our communities can stay safer – and breathe easier – through the end of this year’s flu season. Thanks for your assistance in this vital endeavor.

It varies according to health plan, but flu shots are covered at no cost to our members in most cases. Your patients can call the number on the back of their health plan member ID card to learn more about costs and where they can go to get their shots.

Closing Gaps in Care

It’s hard to believe 2024 is already two months in. As we begin these first months of the year, it’s important to make sure your patients are getting the appropriate preventive services they need, in order to identify any potential issues and close any gaps in their care. As appropriate, please remind your patients about the following screenings.

All Patients:

• Colorectal cancer screening.
• Blood pressure reading.
• Statins therapy for patients with clinical atherosclerosis.
• Seasonal flu vaccine.
• Medication review.
• Annual wellness visit.

Women:

• Breast cancer screening.
• Cervical cancer screening.
• Osteoporosis screening for women who’ve had a fracture.
• Prenatal and postpartum care for pregnant women.

Patients with Diabetes:

• A1C test.
• Nephropathy screening.
• Diabetic retinal eye exam.

Patients with Rheumatoid Arthritis:

• Treatment with a disease-modifying anti-rheumatic drug (DMARD).

Also, please remember we have health coaching and care coordination services that can help your patients manage their conditions at no extra cost to them, if they’re a member of our health plan. We know you worry about your patients’ health between visits, and these services can help improve their health outcomes throughout the entire year.

HEDIS^® Chart Reviews for 2024 (Measurement Year 2023)

To make sure we’re providing our members access to the best care and service, we collect data to determine how we measure up against national averages for HEDIS*. This data collection and analysis is required for National Committee for Quality Assurance (NCQA) accreditation, and it indicates where we need to focus our quality efforts to better serve our members and provider partners.

Here’s how you help us obtain the data and documentation we need to show quality-measure performance:

• We collaborate with providers’ office staff to obtain necessary documentation. Most provider offices and organizations allow access to their electronic medical record (EMR).
• For offices that don’t have an EMR, we can conduct a site visit to obtain the information or fax a request.

We’re gearing up for our HEDIS Data Collection Season that starts this month and ends in May. We’re so thankful for your help.

If you have any questions about HEDIS, or are interested in setting up remote access, contact our Quality Management department at (217) 902-9493 or (800) 851-3379, ext. 9493.

*The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of quality standards that helps us together measure and assess the care and treatments patients receive. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Use well-child visits to check three boxes.

Well-child visits are a great opportunity to get your young patients caught up on all of their health needs. With your help, we can overcome different hurdles and check multiple “health-need boxes” off at once.

Box 1: Well-Child Visits vs. School Physicals

Our HEDIS^* performance for well-child visits has seen some lower rates – and we believe this may be due to parents thinking, incorrectly, that school physicals and well-child visits are the exact same thing.

To meet our HEDIS quality goals, and to better improve the health of your young patients, it’s important they see you for the full-encompassing well-child visit, where many things, including school physical forms, can be addressed.

Box 2: Immunizations

Well-child visits are also a great opportunity to catch up on any missed vaccines. Your young patients may need them for school, sports or simply their own personal health. And remember, parents are more willing to vaccinate after informative conversations with you.

Box 3: BMI, Nutrition and Physical Activity

Lastly, we need your help capturing the discussions you have with your young patients about their BMI, nutrition and physical activity. There are HEDIS quality measures that keep track of whether or not these three things are mentioned in a patient’s chart.

Thank you so much for your help. For more, check out these links:

• Under the headline “Checking In On Your Child’s Health,” find brochures you can share with parents: hally.com/care.
• Find HEDIS tip sheets here: HealthAlliance.org.

*The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of quality standards that helps us together measure and assess the care and treatments patients receive. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Women’s Health: Prenatal Care and Chlamydia Screenings

Prenatal Care

Action: Help us improve our HEDIS* performance for prenatal visits.

Background:

• HEDIS specifications require a prenatal visit to be in the first trimester.
• Early education before pregnancy may help increase your patients’ awareness of the importance of a first trimester visit.
• Thanks to your continued help, our postpartum-care HEDIS rates are doing well: Most patients are seeing their providers within the seven-to-84-day window after delivery that’s specified by HEDIS.

Chlamydia Screenings

Action: Help us improve our HEDIS performance for chlamydia screenings.

Background:

• Our HEDIS performance for chlamydia screenings has been below the national average for at least the last three years.
• One provider partner has changed their language use when talking with patients about chlamydia screenings – with great success.
• Using “opt-out” language (instead of “opt-in”) helps increase your patients’ comfort levels with the discussion and testing.

We deeply appreciate your dedication to the health of your patients. And we’re grateful for your willingness to further their healthy journey by addressing these important HEDIS measures. Thank you.

*The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of quality standards that helps us together measure and assess the care and treatments patients receive. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Children and Adolescents on Antipsychotics

Action: Help us improve the metabolic monitoring of children 1-17 years old who are on two or more antipsychotic medications.

Background:

• HEDIS* quality specifications for metabolic monitoring include testing for blood glucose and cholesterol if your young patients (age 1-17) are on antipsychotic medications.
• Our HEDIS performance is based on the testing of both blood glucose and cholesterol.
• Blood glucose tests that count toward HEDIS: glucose lab, HbA1c.
• Cholesterol tests that count toward HEDIS: cholesterol lab, LDL-C.
• During the calendar year, these tests just need to be run once and they do not have to be ordered by a specific provider type.

Thank you for your help on improving these metabolic monitoring tests. We appreciate your care and attentiveness to your young patients.

*The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of quality standards that helps us together measure and assess the care and treatments patients receive. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Diabetes Care: Help keep your patients’ eyes healthy.

Diabetes can cause serious eye problems. Here are some tips from the CDC about how you can help your patients with diabetes take care of their eyes.

• Discuss the risk of eye disease and vision loss, and how it’s related to having diabetes. Provide them educational materials as necessary.
• Ask about your patients’ vision and eye health at every healthcare visit.
• Make sure they have an established relationship with an eye doctor. Optometrists and ophthalmologists are specialists who are important for the early detection and timely treatment of diabetes-related eye issues (like retinopathy, glaucoma and cataracts).
• Encourage your patients to always get a comprehensive vision exam – including a dilated retinal exam – every single year.
• Tell them to always monitor and watch for changes in their vision. But also remind them that many eye issues do not have recognizable symptoms – that’s why yearly exams are so important.
• Educate your patients about how controlling their blood glucose and maintaining good health can help lower their risk of eye problems.

For more information from the CDC, visit here.

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Coding Counts:
Maintenance of Chronic Conditions

The start of a new year means a fresh chance to close all gaps in your patients’ care. Of key importance to a patient’s overall health status is the maintenance of chronic conditions. Supporting documentation and accurate coding are key to making sure your patients receive the care they need.

• One of the best ways to improve continuity of care for your patients is to document and code all chronic conditions on a yearly basis.
• The sooner the health plan knows about a chronic condition, the sooner we can deploy our care coordination services to support any high-risk patients.
• Accurate representation of the illness burden of your panel is reflected in provider quality ratings (e.g. observed over expected mortality).
• Accurate coding decreases risks for medical errors.

We thank you for your attention to detail and professionalism, and we’re always here to help. To find more coding resources, visit our Coding Counts page. Thank you for your continued care and dedication to our members’ health.

Questions?

Please contact us at CodingCounts@HealthAlliance.org.

Updates to High Cost Medical Drugs List

See the table below for changes to the High Cost Medical Drugs List with effective dates.

Note: Medications removed from the High Cost Medical Drugs List may still require prior authorization.

Note: This article/table only applies to our Health Alliance branded Commercial plans (the plans we refer to as Midwest and Carle in the Pharmacy Updates section below). It does not apply to Health Alliance Northwest or Reid Health Alliance Medicare branded plans.

Note: This article/table does not apply to any of our Medicare plans (no matter what their brand/name).

Midwest – Pharmacy Updates

All Plans

New Drug Reviews/Policies

• Leqembi (lecanemab)—Treatment of Alzheimer disease; to be initiated in patients with mild cognitive impairment or mild dementia stage of disease, with confirmed presence of amyloid beta pathology prior to treatment initiation
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Part B with PA (National Coverage Determination (NCD))
  • Voxzogo (vosoritide)—Indicated to increase linear growth in pediatric patients with achondroplasia with open epiphyses
    • Formulary placement recommendations
      • Commercial—Non-Preferred Specialty Pharmacy with PA
      • Medicare—Non-Formulary

Commercial

New Drug Reviews/Policies

• Kepivance policy
  • Policy created to allow for internal HA review as eviCore no longer reviews for Kepivance

Criteria Changes

• Ulcerative Colitis Immunomodulator Policy
  • Added Entyvio to policy
• Entyvio (vedolizumab)
  • Updated UC review criteria to route to UC immunomodulator policy
• Cosentyx (secukinumab)
  • Added coverage criteria for Hidradenitis Suppurativa
• Forteo (teriparatide)
  • Added step through generic product
• Infertility Medications
  • Updated procedure to include review by pharmacists for appropriate medications per UM-approved treatment regimen

Legislation-Related Policy Creation/Updates

Background

Both Illinois and Washington state have passed legislation effective 1/1/2024 regarding coverage of medications at $0 cost-share to members.

Policies/Updates

These new policies outline how we have adjusted current procedures to remain compliant with this new legislation:

• Washington – Prohibiting Cost-Sharing for Abortion
• Illinois – $0 Cost-Share for Naloxone
• Medications Eligible for Wellness Coverage under the IL Reproductive Health Act

• Related policy updates
  • Korlym (mifepristone)
    • Added exclusion for abortions in accordance with IL Reproductive Act
  • Wellness Coverage for HIV Prophylaxis Regimens
    • Covered at Preventive tier as PEP or PrEP only if indicated in PA request

Formulary Changes—Commercial

Negative Changes (effective 1/1/2024)

• Cabometyx Tablets
  • Add quantity limit of #30/30 days to align with approved dosing
• Xipere (triamcinolone) Ophthalmic Injectable
  • Remove from formulary to align with medical management
  • No current utilization
• Oxandrolone oral tablets
  • Remove from formulary due to FDA approval revoked
  • No current utilization

The P&T committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes and criteria changes are made effective on 1/1 and 7/1, while positive formulary and criteria changes are effective immediately to better serve our members and providers. Upcoming negative formulary and criteria changes can be found here. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Northwest – Pharmacy Updates

All Plans

New Drug Reviews/Policies

• Leqembi (lecanemab)—Treatment of Alzheimer disease; to be initiated in patients with mild cognitive impairment or mild dementia stage of disease, with confirmed presence of amyloid beta pathology prior to treatment initiation
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Part B with PA (National Coverage Determination (NCD))
  • Voxzogo (vosoritide)—Indicated to increase linear growth in pediatric patients with achondroplasia with open epiphyses
    • Formulary placement recommendations
      • Commercial—Non-Preferred Specialty Pharmacy with PA
      • Medicare—Non-Formulary

Commercial

New Drug Reviews/Policies

• Kepivance policy
  • Policy created to allow for internal HA review as eviCore no longer reviews for Kepivance

Criteria Changes

• Ulcerative Colitis Immunomodulator Policy
  • Added Entyvio to policy
• Entyvio (vedolizumab)
  • Updated UC review criteria to route to UC immunomodulator policy
• Cosentyx (secukinumab)
  • Added coverage criteria for Hidradenitis Suppurativa
• Forteo (teriparatide)
  • Added step through generic product
• Infertility Medications
  • Updated procedure to include review by pharmacists for appropriate medications per UM-approved treatment regimen

Legislation-Related Policy Creation/Updates

Background

Both Illinois and Washington state have passed legislation effective 1/1/2024 regarding coverage of medications at $0 cost-share to members.

Policies/Updates

These new policies outline how we have adjusted current procedures to remain compliant with this new legislation:

• Washington – Prohibiting Cost-Sharing for Abortion
• Illinois – $0 Cost-Share for Naloxone
• Medications Eligible for Wellness Coverage under the IL Reproductive Health Act

• Related policy updates
  • Korlym (mifepristone)
    • Added exclusion for abortions in accordance with IL Reproductive Act
  • Wellness Coverage for HIV Prophylaxis Regimens
    • Covered at Preventive tier as PEP or PrEP only if indicated in PA request

Formulary Changes—Commercial

Negative Changes (effective 1/1/2024)

• Cabometyx Tablets
  • Add quantity limit of #30/30 days to align with approved dosing
• Xipere (triamcinolone) Ophthalmic Injectable
  • Remove from formulary to align with medical management
  • No current utilization
• Oxandrolone oral tablets
  • Remove from formulary due to FDA approval revoked
  • No current utilization

The P&T committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes and criteria changes are made effective on 1/1 and 7/1, while positive formulary and criteria changes are effective immediately to better serve our members and providers. Upcoming negative formulary and criteria changes can be found here. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Carle – Pharmacy Updates

All Plans

New Drug Reviews/Policies

• Leqembi (lecanemab)—Treatment of Alzheimer disease; to be initiated in patients with mild cognitive impairment or mild dementia stage of disease, with confirmed presence of amyloid beta pathology prior to treatment initiation
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Part B with PA (National Coverage Determination (NCD))
  • Voxzogo (vosoritide)—Indicated to increase linear growth in pediatric patients with achondroplasia with open epiphyses
    • Formulary placement recommendations
      • Commercial—Non-Preferred Specialty Pharmacy with PA
      • Medicare—Non-Formulary

Commercial

New Drug Reviews/Policies

• Kepivance policy
  • Policy created to allow for internal HA review as eviCore no longer reviews for Kepivance

Criteria Changes

• Ulcerative Colitis Immunomodulator Policy
  • Added Entyvio to policy
• Entyvio (vedolizumab)
  • Updated UC review criteria to route to UC immunomodulator policy
• Cosentyx (secukinumab)
  • Added coverage criteria for Hidradenitis Suppurativa
• Forteo (teriparatide)
  • Added step through generic product
• Infertility Medications
  • Updated procedure to include review by pharmacists for appropriate medications per UM-approved treatment regimen

Legislation-Related Policy Creation/Updates

Background

Both Illinois and Washington state have passed legislation effective 1/1/2024 regarding coverage of medications at $0 cost-share to members.

Policies/Updates

These new policies outline how we have adjusted current procedures to remain compliant with this new legislation:

• Washington – Prohibiting Cost-Sharing for Abortion
• Illinois – $0 Cost-Share for Naloxone
• Medications Eligible for Wellness Coverage under the IL Reproductive Health Act

• Related policy updates
  • Korlym (mifepristone)
    • Added exclusion for abortions in accordance with IL Reproductive Act
  • Wellness Coverage for HIV Prophylaxis Regimens
    • Covered at Preventive tier as PEP or PrEP only if indicated in PA request

Formulary Changes—Commercial

Negative Changes (effective 1/1/2024)

• Cabometyx Tablets
  • Add quantity limit of #30/30 days to align with approved dosing
• Xipere (triamcinolone) Ophthalmic Injectable
  • Remove from formulary to align with medical management
  • No current utilization
• Oxandrolone oral tablets
  • Remove from formulary due to FDA approval revoked
  • No current utilization

The P&T committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes and criteria changes are made effective on 1/1 and 7/1, while positive formulary and criteria changes are effective immediately to better serve our members and providers. Upcoming negative formulary and criteria changes can be found here. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Reid – Pharmacy Updates

IMPORTANT NOTE for Reid Health providers: For your patients with Health Alliance^TM Medicare Advantage plans – previously referred to as “Reid Health Alliance Medicare” plans – please now refer to the above “Midwest – Pharmacy Updates.” The information under the “Medicare” header, along with the specific Medicare listings under the “All Plans” header, are what’s relevant for your patients with Health Alliance Medicare Advantage plans.

Contact Us

 (800) 851-3379, option 3

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