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  • Clinical Practice Guidelines > EmblemHealth-Adopted Clinical Practice Guidelines

    Medical Management

    (Please access these clinical practice guidelines at www.emblemhealth.com.)

    • Adults Exposed to the World Trade Center Disaster
    • Adult Preventive Services
    • Appropriate Use of Antibiotics for Adults and Children
    • Arthritis
    • Asthma
    • Cholesterol Management for Adults at Risk for Cardio/Vascular Disease
    • Chronic Kidney Disease
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Community-Acquired Pneumonia in Adults
    • Congestive Heart Failure
    • Coronary Artery Disease
    • Diabetes Mellitus
    • Helicobacter Pylori
    • HIV/AIDS
    • Hypertension
    • Low Back Pain Diagnosis and Treatment
    • Lyme Disease
    • Obesity and Weight Management in Adults
    • Obesity and Weight Management in Children and Adolescents
    • Osteoporosis
    • Pediatric and Adolescent Preventive Services
    • Preconception Care
    • Prenatal/Postpartum Care
    • Sexually Transmitted Diseases (STDs)
    • Smoking Cessation
    • Stroke Prevention
    • Tuberculosis
    • Urinary Incontinence

    Behavioral Health Services

    Beacon Health Options manages behavioral health services for members served by Emblem Behavioral Health Services Program (for plans underwritten by HIP and HIPIC and administered by VHMS) and Behavioral Management Program (for plans underwritten by GHI).

    Please access the Beacon Health Options Treatment Guidelines listed below at https://www.beaconhealthoptions.com/pcp-toolkit/.

    Diagnosed Based

    Program Based

    Treatment Based

    Medically Fragile Children

    For the Medicaid children carve-in effective July 1, 2018, and the foster care children carve-in in 2019, EmblemHealth
    will incorporate the following into its guidance:

    Office of Health Insurance Programs Principles

    A “medically fragile child” (MFC) is defined as an individual who is under 21 years of age and has a chronic debilitating condition or conditions, who may or may not be hospitalized or institutionalized, and meets one or more of the following criteria:
    (1) is technologically dependent for life or health-sustaining functions,
    (2) requires a complex medication regimen or medical interventions to maintain or to improve their health status,
    (3) is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health, or development at risk. Chronic debilitating conditions include, but are not limited to:

    • bronchopulmonary dysplasia
    • cerebral palsy
    • congenital heart disease
    • microcephaly
    • pulmonary hypertension
    • muscular dystrophy

    With respect to medically fragile children, and children in foster care EmblemHealth:
    A. Will, in accordance with the requirements of C/THP and EPSDT as described in Section 10.4 of the DOH Model Contract, cover all services that assist a medically fragile child in reaching their maximum functional capacity, taking into account the appropriate functional capacities of children of the same age. EmblemHealth will continue to cover services until that child achieves age-appropriate functional capacity.

    B. Shall not base determinations solely based upon review standards applicable to (or designed for) adults to medically fragile children. Adult standards include, but are not limited to, Medicare rehabilitation standards and the “Medicare 3-hour rule.” Determinations have to take into consideration the specific needs of the child and the circumstances pertaining to their growth and development.

    C. Will accommodate unusual stabilization and prolonged discharge plans for medically fragile children, as appropriate. Areas that plans must consider when developing and approving discharge plans include, but are not limited to:

      • sudden reversals of condition or progress, which may make discharge decisions uncertain or more prolonged than for other children or adults
      • necessary training of parents or other adults to care for a medically fragile child at home
      • unusual discharge delays encountered if parents or other responsible adults decline or are slow to assume full responsibility for caring for a medically fragile child
      • the need to await an appropriate home or home-like environment rather than discharge to a housing shelter or other inappropriate setting for a medically fragile child
      • the need to await construction adaptations to the home (such as the installation of generators or other equipment)
      • and lack of available suitable specialized care (such as unavailability of pediatric nursing home beds or
        pediatric ventilator units).

    EmblemHealth will develop a person-centered discharge plan for the child, taking the above situations into consideration.

    D. Will identify an available provider of needed covered services, as determined through a person-centered care plan, to effect safe discharge from a hospital or other facility. Payment will not be denied to a discharging hospital or other facility due to lack of an available post-discharge provider as long as they have worked with EmblemHealth to identify an appropriate provider. EmblemHealth will approve the use of out-of-network (OON) providers if we do not have a participating provider to address the child’s needs.

    E. EmblemHealth will ensure that a medically fragile child receives services from appropriate providers that have the expertise to effectively treat the child. EmblemHealth contracts with providers with demonstrated expertise in caring for medically fragile children. Network providers shall refer to appropriate network community and facility providers to meet the needs of the child or seek EmblemHealth’s authorization for out-of-network providers when participating providers cannot meet the child’s needs. EmblemHealth will authorize services as fast as the enrollee’s condition requires and in accordance with established time frames in the Medicaid Managed Care Model Contract.

    EmblemHealth expects those who treat medically frail and foster children to comply with this guidance.

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    Glossary terms found on this page:

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called Coordination of Benefits.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

    An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

    The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

    A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called a Non-Participating Provider.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    Provides managed mental health and substance abuse (MHSA) programs, workplace services, employee assistance programs (EAP), psychiatric disability management, Medicaid behavioral health management and child welfare programs for over 23 million lives. Visit the ValueOptions Web site at www.valueoptions.com.

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