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Health Outcomes Survey (HOS) season is here! The HOS is administered annually between July and November to a random sample of Medicare Advantage (MA) members. HOS ratings are included in the Star Ratings for MA Quality Bonus Payments.

The goal of the Medicare HOS is to gather valid, reliable, and clinically meaningful health data to use in quality improvement activities, pay for performance, program oversight, public reporting, and to improve health. All managed care organizations with Medicare contracts must participate. In addition to health outcomes measures, the HOS is used to collect three HEDIS^® effectiveness of care measures:

• Management of Urinary Incontinence in Older Adults
• Physical Activity in Older Adults
• Fall Risk Management

What can you do to improve your HOS scores?

• Customize patient-specific care for patients with greater needs.
• Implement a pre-visit checklist to address issues or concerns the patient has raised during previous visits.
• Dedicate time to review health history before a patient’s appointment time.
• Consider using depression screening tools like the Patient Health Questionnaire-9 (PHQ-9) to identify early signs of depression.
• Ask questions to assess if a patient’s mental health affects daily activities.
• Implement a standardized functional assessment tool to monitor patients’ physical activity.
• Initiate the discussion of bladder control with patients and ask if it has affected their daily life or sleep.
• Recommend exercises and discuss treatment options.
• Ask if the patient has fallen since their last visit or had any changes to their walking or balance.

If Medicare-Medicaid dual eligible individuals have their Part A and Part B cost-share fully covered by their Medicaid plan, or are Qualified Medicare Beneficiaries (QMBs), they are not responsible for their Medicare Advantage cost-share for covered services. Please do not balance bill these members for any other costs. Any Medicare and Medicaid payments for services given to these members must be accepted as payment in full. 

For EmblemHealth members, you can use ePACES to check whether the member has full or partial Medicaid benefits. For more detail, see EmblemHealth Medicare Advantage Plans. 

For ConnectiCare members, you can visit CT Department of Social Services or call 800-842-8440. For more detail, see ConnectiCare Medicare Advantage Plans. 

All hospitals and critical access hospitals are required by CMS to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.  

EmblemHealth and its affiliate ConnectiCare Insurance Company, Inc. partner with QualCare and First Health to provide coverage for certain of our benefit plans beyond our own contracted networks’ geographic coverage. These extended networks are considered in-network for our members, based on their geography, as follows:

Bridge Program (EmblemHealth and ConnectiCare)

 QualCare = New Jersey Only

    First Health Network (for EmblemHealth’s companies) = All States except:

• Connecticut
• Massachusetts’s 4 Counties (Berkshire, Hampden, Hampshire, and Franklin)
• New Jersey
• New York’s 28 Counties (Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester)

 ConnectiCare Insurance Company, Inc.’s Flex Network

    First Health Network = All States except:

• Connecticut
• Massachusetts’s 4 Counties (Berkshire, Hampden, Hampshire, and Franklin)
• New York’s 28 Counties (Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester)

Starting Nov. 15, 2022, six CPT Codes (10040, 15730, 17380, 21086, 21087, and 40500) will be added to the preauthorization lists set out below. The additions are a result of our ongoing code list review. The changes align with and support our existing medical policies regarding cosmetic procedures.

• ConnectiCare - Commercial
• ConnectiCare - Medicare
• EmblemHealth Preauthorization List (See Notable Changes announcement.)

CMS’s Quarterly Update for July 2022

In addition, we have updated our preauthorization lists to reflect the code changes shared in CMS’ quarterly update for July 2022.

To easily look up whether a code requires preauthorization, we recommend using the Preauthorization Check Tool in the provider portals.

You may also see the preauthorization lists on our websites (EmblemHealth and ConnectiCare). In the event of a discrepancy, the published list will prevail.

The American Academy of Pediatrics (AAP) recommends hearing screenings for all newborns. The goal is for all babies to have a newborn hearing screening by one month of age, ideally before they go home from the hospital. Hearing problems should be identified by 3 months of age. Those who are identified as deaf or hard of hearing should be enrolled in an early intervention program or treatment by the age of 6 months.

Helpful Tips:

• Obtain chart documents from delivery hospital or perform hearing screening at baby’s first checkup.
• Place EMR alert flag for hearing screening in charts of patients that need screenings completed.
• Obtain parental written informed consent for release of information at first contact with the early intervention program for information to be shared back to the PCP.
• Referrals for an early intervention program should be made to the early intervention office in the county of residence, not the county of birth.

When referring to the early intervention program, be sure to include the following:

Child’s name and date of birth, complete address, dominant language, or mode of communication of child and parent/legal guardian, parent/legal guardian names and address, if different from child, and phone number(s) (multiple numbers if possible), race/ethnicity, reason for referral, developmental concerns, hearing status, testing results completed, and insurance information.

Monkeypox has become a health emergency in our service area, so we are sharing some important resources with our members and providers. Eligibility for monkeypox vaccination may change as the outbreak evolves and based on vaccine supply. People should get two doses, at least four weeks apart. Here are some resources you can use to understand the emergency and share with your patients:

• Centers for Disease Control
• New York State Department of Health
• New York City members can review information at: Monkeypox - NYC Health
• Massachusetts Department of Public Health
• Connecticut Department of Public Health
• New Jersey Department of Health

If you need help navigating our provider portals, see our videos, quick guides, and Frequently Asked Questions pages:

• EmblemHealth Videos and Guides
• EmblemHealth FAQs
• ConnectiCare Videos and Guides
• ConnectiCare FAQs

If you still have questions or need additional support, you may contact Provider Customer Service:

EmblemHealth: 866-447-9717

ConnectiCare: Commercial: 860-674-5850, Medicare: 877-224-8230

EmblemHealth continues to partner with Pulse8™ to promote risk adjustment and gap-closure education for PCPs caring for EmblemHealth members enrolled in these products:

• New York State of Health (NYSOH) Marketplace
• Medicare HMO
• Medicaid

Pulse8 offers free monthly webinars to help educate providers on best practices regarding the risk adjustment process, including accurate medical record documentation and claims coding to capture the complete health status of each patient. We encourage PCPs and/or their support staff to register for Pulse8’s monthly webinars. Go to Pulse8’s Public Event List and search by webinar date or title.


These Pulse8 webinars are generally held on Tuesdays and Thursdays at 8:30 a.m. and 12:30 p.m. Here are the August and September topics:

• Aug. 23/25 – Filtering the Guidelines of Correct Documentation and Coding for CKD and Associated Manifestations
• Sept. 27/29 – Delivering Accurate Codes Related to Obstetrics and Gynecology

If you are interested in learning more about how you can access Pulse8’s provider resources and webinars, please contact Pulse8’s Customer Support team Monday through Friday, 8 a.m. to 8 p.m. at 844-8PULSE8 (844-878-5738) or mail to ProviderEngagement@Pulse8.com. 

We recommend that you take advantage of the training opportunities offered by CMS’s Medicare Learning Network and eMedNY.