October Newsletter

Health Alliance Named Top Plan in Illinois and Iowa

The National Committee for Quality Assurance (NCQA) Private Health Insurance Plan Rankings 2013-2014 and NCQA’s Medicare Health Insurance Plan Rankings 2013-2014 recognize Health Alliance Medical Plans as among the top in the nation and the highest in Illinois and Iowa for Private and Medicare plans.

We appreciate your role in helping us earn these high rankings. They reflect your hard work and genuine dedication to our members and your patients.
Our rankings are:

• Health Alliance Medicare HMO and PPO are each highest-ranked plans in Illinois.
• Health Alliance Medicare HMO ranked 33rd in the nation, and the Medicare PPO ranked 54th in the nation.
• Health Alliance Private HMO ranked #1 in Illinois and Iowa and 55th nationally.
• Health Alliance Private PPO ranked #1 in Iowa and 148th nationally.

The rankings are based on consumer satisfaction, preventive care and treatment, and NCQA accreditation scores as compared to other reporting plans. NCQA sets standards for managed care and recognizes those who perform well. Its scores allow people to compare plans based on quality and premium costs.

NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Date and Information Set (HEDIS^®) is the most widely used performance measurement tool in health care.

Provider Survey Results Are In

The results of our 2013 Provider Satisfaction Survey show that in most areas, our providers are happy with us and our network of doctors, hospitals, and pharmacies. We take your feedback seriously, and we appreciate those who took the time to fill out the survey.

Here are some highlights:

• A strong majority of our providers, 91.5%, are very satisfied/satisfied with us
• 91% of providers were very satisfied/satisfied with our customer service
• The availability of network pharmacies was ranked at 95%
• The quality of network specialists scored 97%
• One of the most important rankings, quality of network hospitals, was ranked at 96%
• 8 out of 10 of the plan attributes scored above 80%, with 6 of those 8 above 90%

Pharmacy

Medicare

Formulary Additions

• Rescula; Tier 4. no restrictions
• Fulyzaq; Tier 4, no restrictions
• Kadcyla; Tier 5, with PA
• Kynamro; Tier 5, with PA
• Ravicti; Tier 5 with PA
• Signifor; Tier 5 with PA
• Mekinist; Tier 5 with PA
• Tafinlar; Tier 5 with PA
• Tecfidera; Tier 5 with PA

Non-Medicare

Formulary Change – Effective October 1, 2013

• Starting October 1, 2013, we will only cover diabetic meters and test strips from Abbott Diabetes Care. We will no longer cover other brands after that date. Abbott offers these preferred test strips:
  • Freestyle Lite
  • Freestyle InsuLinx
  • Precision Xtra
• We instructed our members who do not currently use Abbott products to ask their doctors for a new prescription for Abbott products the next time they need a refill.

Formulary Additions

• Uceris (budesonide ER) – Tier 5 with Preauthorization (PA)
• Invokana (canaglifozin) – Tier 3 with PA
• Zaltrap (ziv-aflibercept) – Tier 5 (Medical Specialty) with PA
• Synribo (omacetaxine mepesuccinate) – Tier 5 (Medical Specialty) with PA
• Xeljanz (tofacitinib) – Tier 5 with PA
• Vascepa (icosapent ethyl) – Tier 3 with PA

Drugs Moving to Tier 2 – Effective September 1, 2013

• Spirivia (tiotropium)
• Delizicol (mesalamine)

Drugs Moving to Tier 3 – Effective January 1, 2014

• Apidra and Apidra Solostar (insulin glulisine)
• Coreg CR (carvedilol extended release)
• Lialda (mesalamine)
• Pentasa (mesalamine)

Drugs Moving to Specialty Tiers (4, 5, 6) – Effective January 1, 2014

• Botulinum toxins (Botox, Dysport, Xeomin, Myobloc) – Tier 5 (Medical Specialty) with PA
• Ozurdex and Retisert – Tier 5 (Medical Specialty) with PA
• Budesonide ER – Tier 4 with PA
• Entocort EC – Tier 6 with PA

Preauthorization Criteria Updates

• Gleevec and Tasigna
  • Available as a first-line agent for CML
  • Other agents for CML, Sprycel and Bosulif, will require a trial and failure of Tasigna prior to use
  • Established patients on Sprycel and Bosulif will not be required to switch to Tasigna
  • Iclusig will be available with identification of the T315I mutation for CML
• Lovaza – PA added for new starts

Remind Patients to Get Recommended Services/Tests

Fall is here, and the final quarter of 2013 has begun. This is a good time to reach out to patients who have not completed recommended services or lab tests.

Our members will soon be receiving reminder letters for these services:

• Members with diabetes who have not had an HbA1c or LDL screening or a diabetic eye exam during 2013
• Members with a history of cardiovascular disease will be notified if they have not had a LDL screening this year
• Women who need cervical cancer screenings or breast cancer screenings
• Medicare Advantage members will be contacted if they have not had glaucoma screening in the past 2 years

These letters urge the members to contact their Primary Care Physician to schedule recommended services. Please make every effort to ensure members who contact your office are scheduled before the end of the year.

In addition, we know that patients are more likely to have tests completed if contacted by their doctor’s office, so we’ll also be sending Primary Care offices a noncompliant report based on HEDIS^® 2013 results. We ask that you review these reports and contact members to encourage them to have the necessary services completed as soon as possible.

Routine Fraud Analysis to Begin on Our Claims

The Centers for Medicare & Medicaid requires all Medicare Advantage plans to make a determined effort to prevent, detect, and correct health care fraud, waste, and abuse. We’ve selected TC3 Health (an Emdeon Company) as a partner in our ongoing effort.

Fraud analysis will be done on all our claims. Provider offices may see an increase in recoupment requests (based on national coding standards) and an increase in medical record requests from us or TC3. If your office has questions about these requests, contact Mark Halbach, our manager of Fraud, Waste and Abuse, at 217-337-3488 or Mark.Halbach@healthalliance.org.

Medicaid Update

As of September 1, we now have active members on our Seniors and Persons with Disabilities (SPD) plan. You might have already seen a patient on this Medicaid plan. They have ID cards that say Health Alliance Connect. In this first year, we hope to enroll about 5,500 members on the SPD plan.

We recently launched our Medicaid website, HealthAllianceConnect.org, as a resource for members and providers. We’re still adding to the site as we get materials approved.

If you have any questions about the SPD plan, contact your provider relations specialist.

Learn More about Marketplace Navigators

Federal law requires states establish a community outreach program, sometimes called navigators or personal assisters, to help eligible individuals purchase health care coverage through the Health Insurance Marketplaces. The counselors will perform impartial outreach, education, and enrollment activities in a culturally and linguistically appropriate manner on behalf of the shopper.  Under the laws of each state, all navigators will be subject to initial training and must complete yearly continuing education requirements to maintain eligibility for their license and certificate renewal.

Illinois recently announced $27 million in federal grants to 44 community groups to help consumers navigate the statewide health insurance exchange this fall.  The groups include well-known clinics, such as Chicago-based Access Community Health Network, as well as advocacy organizations such as the Champaign-based Campaign for Better Health Care. The federal government also announced an award to state health centers to perform similar outreach to facilitate enrollment.

Preauthorization Process FAQs

We receive approximately 4,000 medical service/procedure preauthorization requests each month. Here are answers to some common questions about the process:

Why does Health Alliance require preauthorization?

To provide prospective review of designated planned procedures orservices, using evidence-based criteria and medical policy, to assure member coverage based on plan benefit design.

How does a doctor’s office submit a preauthorization request?

You can submit preauthorization requests:

• Through Clear Coverage, a preauthorization tool that you can access Your Health Alliance for providers and office personnel
• For services not in Clear Coverage, by faxing the request form to the Medical Management Department at 217-337-8440

How long does it take Health Alliance to respond to preauthorization requests?

We’re allowed 15 calendar days from the date of the request for a non-urgent service.

Our average response times are:

• 1.3 days when received through Clear Coverage
• Approximately 3 days when received via fax

Clinical staff can approve requests, but a medical director reviews all potential denials.

To help us respond to the request as quickly as possible, please be sure to include the necessary clinical information with the initial request.

If the request is urgent, as defined by Health Care Reform,* the response time must be within 24 hours. Urgent does not mean that the service has already been scheduled and now the preauthorization decision is needed.

*Urgent means medical care or treatment in which using the timetable for a non-urgent care determination could seriously jeopardize the patient’s life/health or ability to regain maximum function or subject the patient to severe pain that could not be adequately managed without the requested care or treatment, in the opinion of the attending or consulting physician.

What services require preauthorization?

• There is a preauthorization list for all fully insured groups, including Medicare Advantage.
• There is a unique list for the Medicaid population that varies slightly.
• Each self-funded group has its own list.

You can view the member’s preauthorization list by attaching to the member through Your Health Alliance for providers and office personnel.

Note: It is extremely important to verify the correct preauthorization list for the member before submitting the request to assess the need to preauthorize.

If you have any questions not answered here, contact your provider relations specialist.

National Case Management Week Celebrated October 13-19

As Americans seek to put a human face to health care reform laws that may seem like a confusing array of new regulations, Case Management Society of America (CMSA) is working to increase the awareness of patients, providers, payors, and the public about the essential caregiving roles that case managers play.

National Case Management (CM) Week is October 13-19 this year. The observation is a time when we, CMSA, its members, and other organizations work to honor, celebrate, and increase appreciation for the job case managers do in the health care community.

We view case managers as an essential part of the answer to Americans’ need to have a human face on health care. We share CMSA’s goal to advance the profession by helping patients and providers understand how case managers provide support to patients and families navigating the health care system.

We have experienced and highly skilled case managers that guide patients and caregivers through the system, which results in increased coordination of services and improved communication among health professionals on the patient’s team of care providers.

In observance of CM Week, please consider if any of your patients could benefit from having a personal guide as they navigate the health care system or a personal coach as they work on lifestyle changes to reach health goals. Call us at 1-800-851-3379 extension 8112 to make a referral.