June 2018
From Our Chief Medical Officer, Jonathan Welch, MD
Since the beginning of 2018, BMC HealthNet Plan has been experiencing an especially busy period of activity. As you’ll see in this issue of Provider News, the Commonwealth of Massachusetts implemented the largest overhaul of MassHealth in many years with the introduction of Accountable Care Organizations (ACO). On March 1, BMC HealthNet Plan began covering MassHealth recipients through one of four ACOs set up with provider groups in four areas of the state; this has been a monumental undertaking. In addition, the Department of Health and Human Services selected BMC HealthNet Plan to be one of only two health insurers to provide managed care organization coverage to MassHealth recipients. We were also asked by the state to manage the Special Kids Special Care program. Jointly overseen by MassHealth and the Department of Children and Families (DCF), Special Kids Special Care provides intensive medical care management for children who are in the custody of DCF. We’re partnering with Boston Medical Center Pediatrics to provide complex care management to our Special Kids Special Care members.
In this issue of Provider News, we’re also proud to announce that the Centers for Medicare & Medicaid Services awarded us with a very high score for our Senior Care Options program Model of Care renewal. This score comes on the heels of having just expanded our Senior Care Options program into four new Massachusetts counties.
You’ll find the administrative and clinical updates in this newsletter very relevant, so I encourage you to make some time to review all the articles. For example, make sure to pay attention to the piece about the provider section of our website, where you’ll find out how you can save valuable time by conducting many business functions with us – online. In addition, the newsletter has pertinent information for clinicians about depression screening, hypertension, prenatal vitamins, and prescribing statins for patients with diabetes.
As always, your dedicated BMC HealthNet Plan Provider Relations Consultant is there to support you, answer questions, and provide you with the information you need to help ensure your ongoing satisfaction with the services we deliver.
Thank you for continuing to furnish quality care to our members.
ACO Program Goes Live
On March 1, MassHealth launched its Accountable Care Organization (ACO) program, which resulted in an unprecedented membership transition of MassHealth members statewide. Approximately 800,000 members are now being served by 17 ACOs, two managed care organizations (MCO) and the State’s Primary Care Clinician Plan. The BMC Health System has four ACO partners in the MassHealth ACO program:
| Names of ACO Partners | Names of Product Plans |
| Boston Accountable Care Organization |
BMC HealthNet Plan Community Alliance |
| Signature Healthcare Corporation |
BMC HealthNet Plan Signature Alliance |
| Mercy Health Accountable Care Organization |
BMC HealthNet Plan Mercy Alliance |
| Southcoast Health Network |
BMC HealthNet Plan Southcoast Alliance |
There are approximately 170,000 MassHealth recipients enrolled in these four ACOs. In addition, BMC HealthNet Plan is one of the two MCOs selected to participate in the MassHealth program, and we currently serve over 90,000 members through the MCO program.
SCO Model of Care
Following a recent audit by the Centers for Medicare & Medicaid Services (CMS), BMC HealthNet Plan received a score of 98.3% for our Senior Care Options (SCO) program Model of Care renewal. Our Model of Care is now approved from 2019 through 2021. This is an important achievement since, in our first SCO Model of Care approved in 2016, we were very proud to have received a score of 96.67%.
We considered a number of important factors when developing this new Model of Care, including that it:
- is based on providing the best available member care in the most appropriate setting
- links to care management plans and initiatives
- extends across the member journey through different care providers, family members, caregivers, and friends
- supports transitions of care for members between care settings, including upon discharge to home
- minimizes touch points for the member to avoid confusion and to gain and sustain trust
Our Senior Care Options (SCO) program, which became effective in January 2016 in Suffolk County, expanded to four additional Massachusetts counties in 2018: Barnstable, Bristol, Hampden, and Plymouth.
Bmchp.org Offers a Wealth of Provider Support
You can save time by accessing the following BMC HealthNet Plan documents from the Provider Dashboard without a login:
- Medical policies
- Reimbursement policies
- Pharmacy policies
- Durable medical equipment policies (for SCO policies contact Northwood Inc. directly)
- Radiology policies
- Fraud, Waste and Abuse policy
Click on the following links to access the respective documents:
Conduct Important Business Online with a Secure Login
r secure login, you can conduct a number of important administrative functions. This will save you time, reduce costs, and also improve patient satisfaction because you’ll be able to spend more time with them. Once you log in, you can:
- Submit prior authorization requests with the ability to electronically attach clinical records. You also can view the status of a prior authorization request that has been submitted electronically or by fax, phone or postal mail.
- Check claims status. You can view claims status with enhanced detail information, including claims pending adjudication.
- Verify member eligibility
- Check PCP assignment
- View remittance history
- Download useful reports such as your daily inpatient census, PCP panel, emergency room frequent users, and other pertinent reports
Online Prior Authorization Resources
We also offer additional resources to assist you in determining if services require prior authorization, such as our online Prior Authorization Matrix. In addition, our HCPCS Lookup Tool and CPT Code Lookup Tool allow you to type in a code to find out whether the service or procedure requires a prior authorization in the inpatient or outpatient setting.
Special Kids Special Care Program Available Through BMC HealthNet Plan
MassHealth and the Department of Children and Families (DCF) jointly oversee a special medical program known as the Special Kids Special Care program for children with complex medical needs who are in the care and custody of DCF. BMC HealthNet Plan was selected by the Executive Office of Health and Human Services to provide comprehensive, coordinated and integrated managed care coverage and care management services for all program participants. As the new health plan supporting this program since March 1, we are working to ensure that there is no disruption in care or coverage for these members.
To participate in Special Kids Special Care, children must be age 21½ or younger and meet the following MassHealth-defined criteria:
- Be in DCF custody and reside in a foster home or other group setting, or in an adoptive or guardianship home once enrolled in the program, and
- Meet medical criteria that include requiring medical management by or under the supervision of a physician on a regular basis over a prolonged period of time, and either
- Require direct administration of skilled nursing care that necessitates complex procedures (e.g., tube feedings, ostomy care, IV nutrition/medication, tracheotomy tube, ventilator care), or
- Require skilled assessment or monitoring related to an unstable medical condition that may necessitate advanced care or supervision
For PCPs: Under the New ACO Model, Community Partners Will Play an Integral Role in MassHealth Patients’ Care
Over 850,000 MassHealth recipients were affected by MassHealth’s transition this past March from a fee-for-service model to an accountable care organization (ACO) model. Seventeen ACOs were created across the state, including four that the BMC Health System partnered with to offer products under the following names:
- BMC HealthNet Plan Community Alliance
- BMC HealthNet Plan Signature Alliance
- BMC HealthNet Plan Mercy Alliance
- BMC HealthNet Plan Southcoast Alliance
As the next step in the ACO program, the State has selected to contract with 26 Community Partners. These community-based health care and human service organizations will collaborate with the ACOs to integrate and improve member health outcomes for MassHealth members with complex long term medical and/or behavioral health needs. Beginning in July, MassHealth will identify approximately 35,000 ACO recipients who will be eligible to participate in the Behavioral Health Community Partner program, and 24,000 who will be eligible for the Long Term Services and Supports Community Partner Program.
How Do the Two Types of Community Partners Differ?
Behavioral Health Community Partners (BHCP) are community based agencies whose primary role is managing the complex medical, behavioral health and psycho-social issues of MassHealth members with severe, persistent mental illness. Long Term Services and Supports Community Partners (LTSS CP) are community based entities partnering with ACOs and managed care organizations, health care providers, social services organizations, and community resources to support MassHealth members with complex LTSS needs. Access more information about the 18 Behavioral Health Community Partners and eight Long Term Services and Supports Community Partners.
What Does This Mean for Primary Care Practices?
Starting this July, primary care practices may begin receiving calls from Community Partner care coordinators to discuss patients that have been selected to participate in the community partner program. The care coordinator will invite you to join your patient’s care team and assist with developing the person-centered care plan. In addition, the care coordinator will help you enhance your patient’s overall treatment experience by:
- Helping team members understand their patient’s medical and functional needs
- Helping to connect you to your patient’s other health care providers and medication prescribers
- Helping your patient carry out goals of his/her plan of care
- Helping your patient better understand care instructions
Senior Care Options Program: Coverage for Adult Foster Care Services During a Leave of Absence
Adult foster care (AFC) provides Senior Care Options (SCO) members daily assistance with personal care and case management oversight when furnished by the provider in a caregiver’s home.
BMC HealthNet Plan reimburses an AFC provider for the days that an eligible member receives AFC. An AFC provider may not bill for non-service days, and we do not pay for any days during which an eligible member does not receive AFC. The exception is a medical leave of absence or nonmedical leave of absence. A medical leave of absence is a short-term absence from an AFC-qualified setting during which a member does not receive AFC from the AFC caregiver because the member is admitted to a hospital, nursing facility or other medical setting. A non-medical leave of absence is a short-term absence from an AFC-qualified setting during which a member does not – for reasons other than a medical leave – receive AFC.
For a medical leave of absence, we reimburse an AFC provider for a maximum of 40 days each calendar year if the member is admitted to a hospital or nursing facility. In addition, we reimburse an AFC provider for a short-term non-medical leave of absence for up to 15 days each calendar year if the member is away for non-medical reasons.
SCO AFC providers should monitor and document both medical and non-medical leaves of absences since we may request documentation during the course of an audit or other review. Please review our SCO Adult Foster Care Reimbursement Policy (Policy Number: SCO 4.21 for more details. Access other SCO reimbursement policies.
Prescribing Prenatal Vitamins
Massachusetts Medicaid recipients can receive generic over-the-counter prenatal vitamins - free of charge - with a prescription. Prenatal vitamins are an important factor to help ensure that mom and baby are healthy, so please remember to write a prescription for them.
If you need to prescribe a specific brand of prenatal vitamins, make sure to check the BMC HealthNet Plan online over-the-counter medication formulary to find out if they're covered.
Screening Adolescents and Adults for Depression
Depression is a common behavioral health condition and one of the leading causes of disability in adolescents and adults (ages 12-64). It’s important to screen these groups for depression using approved, standardized tools such as those listed below.
Acceptable tools for the adolescent population:
- Patient Health Questionnaire (PHQ-9)®
- Patient Health Questionnaire Modified for Teens (PHQ-9M)®
- PRIME MD-PHQ2®
- Beck Depression Inventory-Fast Screen (BDI-FS)®*
- Mood Feeling Questionnaire (MFQ)*
- Center for Epidemiologic Studies Depression Scale (CES-D)
- PROMIS Depression
Acceptable tools for the adult population:
- Patient Health Questionnaire (PHQ-9)®
- PRIME MD-PHQ2®
- Beck Depression Inventory (BDI-II or BDI-FS)®*
- Center for Epidemiologic Studies Depression Scale (CES-D)
- Depression Scale (DEPS)
- Duke Anxiety-Depression Scale (DADS)®
- Geriatric Depression Scale (GDS)
- Cornell Scale for Depression in Dementia (CSDD)
- Edinburgh Postnatal Depression Scale (EPDS)
- My Mood Monitor (M-3)®
- PROMIS Depression
- Clinically Useful Depression Outcome Scale (CUDOS)
Patients screening positive for depression should have a follow up visit within 30 days.
Help Finding a Therapist
Beacon Health Options, BMC HealthNet Plan’s behavioral health partner, is available to provide assistance in finding the right doctor or therapist for your patients. Call Beacon at 866-647-2343 to discuss or consult with a Beacon psychiatrist about behavioral health issues such as psychopharmacology and also to determine when to refer a patient for a psychiatric assessment. For additional resources and information on the PCP Toolkit, you can visit Beacon’s website.
Remember to Conduct a Behavioral Health Screen
We want to remind primary care providers to conduct behavioral health screens at all well child visits for MassHealth members ages birth to 21 years. Find MassHealth approved screening tools on their website.
Statin Therapy is Recommended for Patients with Diabetes
The Standards of Medical Care in Diabetes – 2018 from the American Diabetes Association recommend annual assessment for cardiovascular disease. Based on these standards, patients should be stratified into two categories: those with arteriosclerotic cardiovascular disease (ASCVD) and those without. Risk factors include hypertension, dyslipidemia, smoking, and a family history of premature coronary disease.
For patients with diabetes and ASCVD, the standards recommend high intensity statin therapy along with lifestyle changes. When you prescribe statins, it’s important to educate patients and stress the importance of medication adherence to help reduce cardiovascular risks. Link to our online formulary to identify statins.
Blood pressure control is also important and should be below 140/90 for patients without ASCVD risks, and less than 130/80 may be appropriate for individuals at high risk for ASCVD. You also should stress self-management skills for lipid control, including weight management, physical activity, smoking cessation, and medication adherence.
Please see the article in this newsletter about preventing hypertension for additional recommendations, particularly around self-monitoring.
You should also go to our website to link to the American Diabetes Association Standards of Medical Care in Diabetes–2018.
Prevent Hypertension
According to the Eighth Joint National Committee Guidelines for the Management of Hypertension in Adults, hypertension is one of the most important preventable contributors to disease and death in the U.S. If it is not detected early and treated appropriately, it can lead to infarction, stroke and renal failure. The guidelines recommend that pharmacologic treatment should be initiated when blood pressure is above 140/90 for individuals with diabetes or younger than 60 years of age, and for individuals over 60 years of age with blood pressure that is above 150/90.
Tracking Blood Pressure
Patients should self-monitor and track their blood pressures so that treatment modifications can be implemented. We suggest that you ask your patients to bring in their blood pressure readings logs for review at appointments and incorporate the information into patients’ medical records, including the date and reading.
In addition to pharmacological treatment, we encourage you to discuss with your patients issues such as lifestyle changes that include healthy diet, weight control, smoking cessation, and regular exercise.