SPRING 2012 
  In This Issue:

Medicare and Medicaid Updates

Introducing Care360

EmblemHealth Injectable Drug Utilization Management Program Begins

Claims Corner

Utilization Review Criteria Update

Medical Director Availability After an Adverse Determination

Member Rights and Responsibilities

Provider Advisory Webinars a Success

CAHPS Member Satisfaction Surveys Are in the Field!

Behind the Scenes

Colorectal Cancer Screening

Medication Adherence for Chronic Conditions

Medical Management of COPD

Dental Hygiene Is Important

How to Help Your Patient With ADHD

Your Role in Slowing the Obesity Epidemic

Health and Wellness Programs

What Is a Health Outcome Survey?

Clinical Corner

News&Notes Archive

Medicare and Medicaid Updates

SBIRT Credentialing Process

In September 2011, we informed practitioners that the Screening, Brief Intervention and Referral to Treatment (SBIRT) policy for Medicaid managed care and Family Health Plus members expanded to include certified primary care physicians. In response to this modification, EmblemHealth is credentialing practitioners for SBIRT services as part of our credentialing/recredentialing process.

EmblemHealth Provides MLTC

New York has instituted policies that will affect recipients of both Medicare and Medicaid who need at-home benefits. Patients who receive over 120 days of at-home care need to choose and enroll in a Managed Long-Term Care (MLTC) plan before these changes are implemented. After 120 days, the State of New York will assign patients to a plan that may not be their first choice. This could mean different at-home care providers for your patients.

EmblemHealth has a Medicaid Advantage Plus MLTC plan that offers our members quality HMO health care coverage along with at-home care at no extra charge. Or, they can choose the MLTC Partial Plan that solely provides at-home care. Members would then be eligible to receive the following services:

  • Personal care
  • Help with chores and housekeeping
  • Adult day health care
  • Social adult day services
  • Delivered meals
  • Personal emergency response systems

We want our members, your patients, to enjoy the best quality of life possible. Members can get additional information about the Managed Long-Term Care programs offered by EmblemHealth by calling 1-888-447-9161.

New York Initiates the Provider-Led Health Home Program

Under the Federal Patient Protection and Affordable Care Act (ACA), New York has developed a set of health home services for Medicaid members who have been diagnosed with severe mental illness, substance abuse issues or HIV+/AIDS or with two or more chronic medical conditions.

The program is offered to targeted EmblemHealth Medicaid and Family Health Plus members designated by the New York State Department of Health. Eligible members are assigned to a Provider-Led Health Home in their county of residence. The Health Home is responsible for enrolling our members and contacting their primary care physician and other practitioners as part of the development of a comprehensive care plan. The contact with you is important because the comprehensive plan seeks to integrate treatment plans from a member's health care providers. Your patient may choose to opt out at any time.

Currently the program is offered in three counties in the downstate area:

  • Bronx
  • Kings (Brooklyn)
  • Nassau

Additional counties, including New York, Queens, Richmond (Staten Island), Suffolk and Westchester will be added shortly.

Patients will receive the following services through the Health Home program:

  • Comprehensive case management with an assigned, personal case manager
  • Help and encouragement in getting necessary tests and screenings
  • Help and follow-up when leaving the hospital and going to another setting
  • Personal support and support for their caregivers or families
  • Referrals and access to community and social support services

Learn more about the Provider-Led Health Home program. If your patient is eligible and has been assigned to a Provider-Led Health Home, encourage your patient to participate and take advantage of these enhanced services.

Medical Supplies for Medicaid Members

Prior to October 1, 2011, Medicaid Fee for Service covered pharmacy benefits for Medicaid members, which included prescription and over-the-counter drugs, and medical supplies. Under the Medicaid program, members were able to take their prescriptions to any pharmacy that accepted their Medicaid card and receive their drugs and medical supplies.

As of October 1, 2011, Medicaid member pharmacy benefits are covered by HIP and members must use HIP network pharmacies to fill their prescriptions. Members can get many, but not all, medical supplies by taking their prescription to any HIP network pharmacy. To fill prescriptions for medical supplies, members should:

  • Call their pharmacy first and ask if they can fill their prescription.
  • Have their prescription handy in case they are asked to give information listed on their prescription.

You or the member can order medical supplies by contacting one of our network medical supplies vendors.

If you have questions about how to fill prescriptions for medical supplies for Medicaid members, call Customer Service at 1-866-447-9717, Monday through Friday, between 9 am and 5 pm. A representative will be happy to help you.


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