Midwest December Newsletter

New CMS Training Requirements

Starting in 2016, all Medicare Advantage organizations and Prescription Drug Plan sponsors, like Health Alliance Medicare, will be required to provide general compliance and fraud, waste, and abuse (FWA) training for all employees of their organization and for the first-tier, downstream, and related entities (FDRs) they partner or contract with to provide benefits or services.

If you have a contractual relationship with Health Alliance Medicare, you are considered an FDR, and you and all your employees are required to complete this training.

Please ensure that you and your employees complete the general compliance and/or FWA training modules located on the Centers for Medicare & Medicaid Service’s (CMS) Medicare Learning Network (MLN). Choose “Web-Based Training Courses” under “Related Links” to get to the training modules. The MLN system-generated certificates of completion will serve as evidence of compliance.

You must maintain certificates or documentation of training completion (certificates of completion, training logs, system-generated reports, spreadsheets, etc.), containing at least employee names, dates of employment, dates of completion, and passing scores (if captured), for 10 years.

All Our Government Programs Now Under Health Alliance Connect

Our 2 government programs that were previously not under the Health Alliance Connect are now being transferred to fall under this line of business.

Please note that this only affects Illinois members and providers.

As a reminder, we our discontinuing our Medicaid-Medicare Alignment Initiative (MMAI) plan as of December 31, 2015.

Illinois Partnership for Health (IPH)

On November 1, 2015, IPH members in the Central Illinois 15-county region were transitioned to Health Alliance Connect. We sent members new ID cards that identify them as Health Alliance Connect members.

Because these members are now under Health Alliance Connect, please forward all claims with a date of service of November 1 and after to Health Alliance; do not submit them to the State of Illinois. For services that require preauthorization, please follow the Health Alliance Connect preauthorization list.

The rest of the IPH members in Northern Illinois (Rockford and Quad Cities area) will be transitioned on January 1, 2016.

Dual-Eligible Special Needs Program (D-SNP)

D-SNP will be transferred to Health Alliance Connect on January 1, 2016. This is for business/tax purposes only, and members will still be referred to as Health Alliance Medicare members on all member or sales materials.

Wellness Code Update

Effective January 1, 2016, CPT 82271 will no longer be a wellness code.

As a reminder, code A9274 is considered investigational and is not covered.

Assistant Surgeon Reimbursement Rate Change

Effective January 1, 2016, Health Alliance is changing the reimbursement for assistant surgeons from 25% to 20% to align with CMS standards. If you have any questions about this change, please contact your provider relations specialist.

Public Exchange Offerings

Open Enrollment for people signing up for health insurance through the public exchange on HealthCare.gov began on November 1, 2015, and runs through January 31, 2016.

Here’s a quick overview of the plans Health Alliance offers through the public exchange:

Individual Plans

• Plans available in – Illinois and Washington
• Types of plans – PPO, POS, HMO
• Network – Health Alliance narrow network. Our marketing in Illinois focuses mostly on the Riverside network, which is the same network other Health Alliance plans offered in the area have, except it is branded with the Riverside name. These Riverside-branded plans are only sold in Grundy, Iroquois, Kankakee, and Will counties.

Small Business Health Options Program (SHOP) plans

• Plans available in – All Illinois counties except Cook, DuPage, Kane, Lake, and McHenry
• Types of plans – PPO, POS, HMO
• Network – Health Alliance narrow network, same as individual public exchange plans

Pharmacy Updates

All Plans

Formulary Additions

• Orkambi (lumacaftor/ivacaftor) – the first CFTR targeted therapy approved for use in cystic fibrosis patients with homozygous F508del mutations.
  • Commercial – Tier 5 with preauthorization (PA)
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Praluent (alirocumab) – the first FDA-approved Proprotein Convertase Subtilisin Kexin type 9 (PCSK9) inhibitor available on the market.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Repatha (evolocumab) – the second FDA-approved PCSK9 inhibitor available on the market.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA

Medicaid

Tier Changes – Effective 12/1/15, pending state approval of member notification letter

Moved from covered to not covered:

• Clindagel
• Xolegel
• Tersi Foam
• Lokara
• Cormax Scalp Application

Policies Presented for Off-Cycle Approval – 9-15 – E-Vote

• Medicaid – Controlled Substance Prescription Limit
• Medicaid – Insulin Pens
• Medicaid – Restricted Member Access to Pharmacies or Prescribers
• Medicaid – Test Strip Quantity Limitation

Upcoming Change

These birth control medications are in the process of being removed from the Medicaid formulary. Further member and provider notifications will follow with covered alternatives:

• Beyaz
• Natazia
• Ortho-Tri-Cyclen Lo
• Lo Loestrin FE
• Safyral
• Depo-Provera SubQ 104

Medicaid & Commercial

Formulary Additions

• Daklinza (daclatasvir) – a new NS5A inhibitor approved for use in combination with Sovaldi, a NS5B polymerase inhibitor, for treatment of genotype 3. Daklinza plus Sovaldi is the first FDA-approved, interferon-free, ribavirin-free 12-week regimen to treat genotype 3.
  • Commercial – Tier 6 with PA
  • Medicaid – Covered with PA
• Technivie (ombitasvir/paritaprevir/ritonavir) – the first approved interferon-free, once-daily oral regimen to be used in combination with ribavirin for the treatment of hepatitis C genotype 4 without cirrhosis.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA

Criteria Changes

• Tazorac – added coverage for plaque psoriasis
• Modafinil – removed step through Nuvigil, effective 1/1/16
• Aripiprazol – specified coverage for major depressive disorder, bipolar disorder, and schizophrenia
• Brand Atypical Antipsychotics – requires 2 generic atypical antipsychotics
• Lyrica – removed step through gabapentin, added PA based on indication

Quantity Limits

Updated 30-day quantity limits for ADHD medications.

Commercial

Formulary Additions

• Arnuity Ellipta (fluticasone furoate) – branded inhaled corticosteroid (ICS) for the maintenance treatment of asthma.
  • Commercial – Tier 3 with PA
• Incruse Ellipta (umeclidinium) – a long-acting muscarinic antagonist (LAMA) for the long-term, once-daily, maintenance treatment of airflow obstruction in patients with COPD.
  • Commercial – Tier 3
• Stiolto Respimat (tiotropium bromide/olodaterol) – joins Anoro Ellipta as the second branded fixed dose LAMA/LABA combination product for maintenance treatment of COPD.
  • Commercial – Tier 3 with step therapy
• Entresto (sacubitril/valsartan) – the first agent in a new class of drugs referred to as angiotensin receptor-neprilysin inhibitors (ARNIs) indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.
  • Commercial – Tier 3 with PA

Tier Change – Effective 12/1/15

Cimzia – Moved from Tier 4 to Tier 5

Involving Patients in Healthcare Decisions

Shared decision-making is a model of patient-centered care that enables and encourages patients to play a role in their own healthcare management. It operates under the belief that patients can and will take part in making decisions about their health care if they have access to the information and answers they need to understand their health issues and options.

The first step in shared decision-making is to help patients become informed about their health and any conditions they have. You can help educate them by answering their questions, giving them any relevant pamphlets or brochures you have, and directing them to more information online.

Once patients are appropriately informed, the next step is for you and your team to involve the patients in making decisions. Go over the treatment options and ask questions about their needs, values, and preferences to decide together on the best choice for them.

Not every patient will be able and willing to help make healthcare decisions, but you should offer everyone that opportunity. Evidence suggests that the majority of patients do want more information and greater involvement in making decisions about their health.