Welcome to Magellan Complete Care

Transcription

1 Magellan Complete Care of Florida Provider Newsletter Welcome to Magellan Complete Care On behalf of Magellan Complete Care of Florida, thank you for your continued support and collaboration. As the only SMI specialty plan of its kind in the country, we look ahead to 2015 as an opportunity to work together in order to continue our mission of improving the health and lives of our members, their families and the communities we serve was quite a year for Magellan Complete Care of Florida. We successfully accomplished the monumental task of launching and delivering a unique model of care. We experienced remarkable growth with the development of an impressive PCP network, the steady increase of our member base, and the unveiling of a one of a kind integrated model of care that reflects the needs of our members. Now, in 2015, we continue to focus on delivering on our promise and passion to create valuable and relevant access to care for our members. The success stories we are receiving are a true testament to your hard work, dedication and quality care that you deliver. We look to you, our valued providers, as teammates who will assist us as we deliver unique solutions to our vulnerable member population. We challenge you to communicate and work in concert with your behavioral and physical health colleagues, mental health counselors, care workers, community resources and family members. Familiarize yourself with Magellan Complete Care s Provider Support Specialists, who are in your community exclusively to support you in providing high-quality, clinically appropriate health care, tailored to each member s needs. We urge you to communicate and work together with other disciplines providing services to your patients, our members, to best achieve common and mutually beneficial growth. Let your commitment to quality and holistic care make the difference and serve as a catalyst. We rely on you to embody the integrated infrastructure we are working so hard to develop one that supports and promotes recovery and ultimately strengthens the communities where we live, work and play. In the next several pages you will find our inaugural Provider Newsletter. Four times a year we will post, and fax you helpful information on a variety of topics ranging from clinical practice guidelines and community based services, to specific plan measures and claims updates. We encourage you review the information and visit our website frequently for resources and up to the minute changes in plan oversight. We ask that you share this information and become familiar with protocols and important dates. We welcome you to the 2015 Magellan Complete Care of Florida network. We look forward to another year of delivering one of a kind high-quality health care tailored to our member s unique needs. We understand that our success is dependent on your participation in our network and look forward to working together to deliver the Magellan Complete Care difference every day. For more information call us at or visit MagellanCompleteCareofFL.com Issue 1 February 2015

2 Magellan Complete Care Introduces Care Transition Services What are Care Transition Services? Transitions from a hospital or a skilled nursing facility to home can often be more complicated for people with serious mental illness. This is due to their complex medical and behavioral health needs that can pose significant challenges in management. Magellan Complete Care s high contact Care Transition Services focus on helping members who are experiencing complex physical and behavioral health concerns. Through the integration of a Care Transitions Team, the specialty plan members who are being treated in a hospital receive coordinated hospital to home services as they complete their recovery. Magellan Complete Care utilizes Care Transition Services in order to help members transition smoothly from a hospital or skilled nursing facility to their home, preventing avoidable hospital readmissions. Comparable programs across the country have used similar approaches successfully resulting in significant reductions in avoidable hospital readmissions. How Care Transition Services Work Upon admission to a participating hospital, one of Magellan Complete Care s skillfully trained Health Guides will reach out either in person or telephonically to the member and their caregiver. The Health Guide will engage the member about their condition and discharge plan in order to determine the type of support the individual will need when they go home. Once home, the Health Guide will stay in contact with the member in order to assist in a number of different ways, such as: Assessing the member s living conditions and overall safety; Educating the member and caregiver on their discharge plan; Describing how to obtain and take their medications properly; Explaining the signs and symptoms that may necessitate a call to the primary care provider, or other health professionals, as well as the importance of having follow-up provider visits; Assisting with meals, transportation, and health provider appointments; Assisting with equipment and supply ordering; and, Assisting with Access to 24 hour Nurse Line services. The Health Guide will also coordinate with a Magellan Complete Care Integrated Care Case Manager who will be assigned to each member. We will be reaching out to you in the next several weeks to discuss the program. If you have any questions, please call us at your convenience at or Kale Baker at [email protected]. Important Quality Measures Magellan Complete Care monitors the quality and performance of each of our participating providers. We will be establishing a plan and method of communicating with you regarding your baseline rates for each applicable measure. Beginning in late 2015, Magellan Complete Care will monitor the following measures: 1. Diabetes monitoring for members with diabetes & schizophrenia or bi-polar disorder who are using anti-psychotic medications; 2 Magellan Complete Care of Florida

3 2. Behavioral Health & Medical readmission rates; 3. Adult access to preventive/ambulatory health services; 4. Breast cancer screening; 5. Cervical cancer screening; 6. Use of appropriate medications for people with asthma; and, 7. Lithium monitoring for members on Lithium. We appreciate your participation in our network and look forward to working together to achieve high standards of quality care and service for our members. If you have any questions about any of the performance measures that Magellan Complete Care will monitor, you may contact our Network Team at (800) Healthy Behaviors Program Launches February 1st On February 1, 2015, Magellan Complete Care launched the Healthy Behaviors Program. Magellan Complete Care has a contractual agreement with AHCA to provide the Healthy Behaviors Program in order to engage members and reward them for making healthy lifestyle changes. The program offers incentives to members who successfully meet the goals of each program. The three programs being offered are: Tobacco Cessation Weight Management Substance Abuse Treatment The Healthy Behaviors Program will require Magellan Complete Care providers to assess and educate members during their participation in the programs. A particular requirement for the providers will involve the Weight Management program. Members will present providers with a PCP Verification Form wherein you must print, sign and date in order to verify the achievement of a specific weight loss goal. This form, along with additional tools and helpful assessments, can be found on our website at: Additional expectations include encouragement and education for these members as they begin their journey towards a healthier lifestyle. We appreciate your continued collaboration and support of our members, and we know that working together as a team will assist in enhancing their wellbeing. Magellan Complete Care Introduces Whole Health Rx What is Whole Health Rx? Whole Health Rx is an evidence based information system that allows you to identify and manage patients that have behavioral health conditions and common co- morbid physical conditions. It is: A cost free, comprehensive and integrated approach for managing a patient s health and drug management. A program that provides information about medications to assist you in your efforts to provide safe, appropriate and cost effective care for your patients. A tool that connects primary care physicians, behavioral health providers and nurse practitioners to identify and resolve gaps in care. What is Our Goal? To improve patient outcomes by providing support and information that coordinates the patient s whole health and recognize those who: Are non-adherent to core psychotropic medications. Have likely stopped their mood stabilizer and have previously been diagnosed with bipolar disorder. May not have received recommended laboratory tests. Are receiving therapy with significant drug-drug interactions. Magellan Complete Care of Florida 3

4 Verify Your Data on the PML We urge providers to please check periodically to make sure that the data present on Florida Medicaid s Provider Master List (PML) is accurate and up to date. The data provided on the PML is used by Florida Medicaid to validate provider information sent via encounter data. Therefore, accuracy and up to date information is of the utmost importance. Some of the key data elements that should be verified are: 1. Florida Medicaid Provider ID Number 2. Provider Type Code 3. Provider Specialty Code 4. NPI 5. Taxonomy Code 6. Zip Code Attention Providers: Magellan Complete Care would like to clarify that our enrollees are able to obtain community care management services as medically necessary at any time. Recently, we received feedback that there is confusion in the community regarding Magellan Complete Care s health plan management being a substitute service for community case management. This is not accurate. Regardless of the services provided by our plan, Magellan Complete Care enrollees are eligible for community-based services HEDIS Corner Magellan Complete Care supports your efforts in providing strong evidence based care to your patients. To that end, we promote and monitor use of the Health Effectiveness Data and Information Set (HEDIS) measures as developed by the National Association of Quality Assurance (NCQA). We believe it s important for our network practitioners to understand and ensure members who meet specific care needs are supported to be compliant with care and testing. The information below provides a summary of selected measures specific to the Magellan Complete Care population, both disease state and preventive care. We encourage you to work in collaboration with your patients to obtain the required preventative care. As we move forward, we will provide additional information on HEDIS measures and outcome results. If you have any questions or need additional information regarding the measures or expectations as you treat your patients, please do not hesitate to contact us at HEDIS Corner SMI Plan Specific Measures Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotics. Members years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication should have an annual diabetes screening test (glucose or Hba1c test) each year. This excludes those with Diabetes. Diabetes monitoring for people with diabetes and schizophrenia. Members years of age with schizophrenia and diabetes must have an LDL-C test and an HbA1c test each year. Cardiovascular monitoring for people with cardiovascular disease and schizophrenia. Members years of age with schizophrenia and cardiovascular disease must have an LDL-C test each year. Adherence to antipsychotic medications for individuals with schizophrenia. The actual measure: The percentage of members years of age during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period. This is a complex measure and there are several exclusions. Most members years of age during the measurement year with schizophrenia should remain on an antipsychotic medication as appropriate. HEDIS Corner Mental Health and Substance Abuse Antidepressant Medication Management. Members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression should obtain a consistent antidepressant medication treatment. There are two measures. They look at 12 weeks of continuous treatment and 6 months of continuous treatment for the HEDIS measures. 4 Magellan Complete Care of Florida

5 Follow-up Care for Children Prescribed ADHD Medication. Children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication should have at least three follow-up care visits within a 10-month period: first visit is within 30 days of prescription fill, then two additional visits after within the next 9 months. Follow-up after Hospitalization for Mental Illness (7 days). Members 6 years of age and older who were hospitalized for treatment of a mental illness needs to have an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner within 7 days of discharge. This excludes members who are transferred to a non acute facility. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment. Members 13 years and older with a new episode of alcohol or other drug (AOD) dependence identified by an inpatient, intensive outpatient, partial hospitalization, outpatient, detoxification or ED visit should obtain AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of diagnosis. HEDIS Corner Other Preventative Care Adults Access to Preventive/Ambulatory Health Services. Each member 20 years and older must have an ambulatory or preventive care visit each year. Annual Dental Visits. Members 2 21 years of age must have at least one dental visit each year. BMI Assessment. Members years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. The patient s weight and BMI value must be documented in the members chart. The provider can also document the BMI value by using the appropriate ICD-9-CM V codes. Keeping Your Profile Current Magellan Complete Care monitors the quality and performance of each of our participating providers. We will be establishing a plan and method of communicating with you regarding your baseline rates for each applicable measure. Beginning in late 2015, Magellan Complete Care will monitor the following measures: Diabetes monitoring for members with diabetes & schizophrenia or bi- polar disorder who are using antipsychotic medications; Behavioral health and medical readmission rates; Adult access to preventative/ ambulatory health services; Breast Cancer Screening; Cervical Cancer Screening; Use of appropriate medications for people with asthma; and, Lithium monitoring for members on Lithium. Breast Cancer Screening. Women ages should have a mammogram at least every three years. Cervical Cancer Screening. Women ages must be screened for cervical cancer every 3 years by performing either a cervical cytology or for women years old have a cervical cytology/ human papillomavirus (HPV) co-testing performed every 5 years. Children and Adolescents Access to Primary Care. Children between 1 year and 6 years old must have an annual PCP visit. Children between 7 and 19 years old must have a visit every two years. Chlamydia Screening for Women. Women years of age who were identified as sexually active must have at least one test for Chlamydia during the measurement year. Magellan Complete Care of Florida 5

6 Understanding OTC Benefits and the Need for a Prescription What are the OTC benefits for Magellan Complete Care Members? $25 per household per month to use toward Magellan Complete Care of Florida approved OTC drugs with an NDC on the list. The balance will be set to $25 at the beginning of each month. The balance does not roll over month-to-month. A prescription will be required No clinical, PA or limitation edits are applied. Only the following ProDUR edits apply: Early Refill (ER) and Drug to Drug (DD). Covered OTC drugs do not require rebate coverage. Claims are limited to submission via POS (no batch or paper). There are no beneficiary submitted claims. Need to accumulate balance within FRx. Provide message at POS to include patient benefit balance for current month. Call center will be able to view the balance in FirstTrax to support calls. Monthly limit is $25; unused portions may NOT rollover into the next month. Lesser of payment logic applies, using same algorithms for reimbursement per contractual requirements. The dispense fee will also pay per contractual requirements and is part of the $25 limit. Any/all Magellan pharmacy network providers may participate in this program. Beneficiaries who are disenrolled during the month will no longer have access to the benefit for the remainder of that month. Use Recipient ID for claim submission. Helpful Tips for OTC Benefits The OTC List will be reviewed every six months by the Magellan Complete Care of Florida UM committee; or on an as needed basis. Any changes will be provided. The beneficiary is responsible for paying any difference between the calculated paid amount and the amount of their remaining credit line (e.g. beneficiary has $10 credit, claim is paid for $15; hence beneficiary to pay $5 difference. Go to completecareoffl.co m/fl- site/ providers/prefer red-drug-list/ over-the-counter-benefits.aspx for Magellan Complete Care of Florida approved OTC drugs with an National Drug Code on the list. C-N1101rev1 (3/15) 2015 Magellan Health, Inc.