Office Visit

Hello colleagues, 

This month, I want to share our perspective on social determinants of health (SDOH). SDOH is a term that covers so many areas. SDOH are the non-medical factors that influence health outcomes. They are the conditions of the environments where people are born, live, learn, work, play, worship, and age. They include:

• Economic stability.
• Education access and quality.
• Neighborhood and environment.
• Health care access and quality.
• Community and social supports.*

*Social Determinants of Health - Healthy People 2030 | health.gov

Addressing SDOH at a population health level is complex and challenging. (Think of things like federal, state, and local politics; regulations; budgets; etc.) But we have tools to help you and your patients.

SDOH account for 30% to 55% of our health outcomes (World Health Organization [WHO], 2022). That means keeping patients healthy goes beyond identifying and treating illness and making recommendations for preventive care such as diet and exercise. As important as those things are, we also want to support you in understanding and addressing the bigger picture. For example, a recommendation to eat better cannot be followed by someone who cannot get healthy food.

SDOH is so important in the regulatory aspects of health plans, NCQA has added a new HEDIS measure for screening and providing interventions for transportation, food, and housing. 

There is so much to say on this topic. Next month, we will begin to look at our three-pronged approach to SDOH: identify the barrier, listen to members and collect information, and identify reliable solutions.

Until then, here are resources that can help you:

• Quality Measures Resource Guide
• EmblemHealth Neighborhood Care
• ConnectiCare Centers
• EmblemHealth Care/Case Management Programs
• ConnectiCare  Care/Case Management Programs

Lama

Lama El Zein MD, MHA

Sr. Medical Director/Population Health

If there are other health topics you would like our perspectives on, please write to us at :

emblemhealthmedicaldirectors@emblemhealth.com.

While we welcome your suggestions, we ask that you do not send protected health information (PHI) or patient-specific issues to this mailbox. This mailbox should not be used for Complaints, Grievances, Appeals, or Claims Inquiries. The Claim Inquiry and Message Center features in the provider portals (EmblemHealth | ConnectiCare) should be used for those issues.

Starting Jan. 1, 2023, EmblemHealth will no longer require primary care provider (PCP) referrals for specialty care for Medicaid (Enhanced Care), HARP (Enhanced Care Plus), and Child Health Plus (CHPlus) members. Additionally, EmblemHealth CHPlus member ID cards will be updated and reissued to reflect this change. 

Providers must notify Medicaid of any change of address, telephone number, or other pertinent information within 15 days of the change. For more information on this requirement and how to submit changes, see Reminder: Keep Your Directory Data Current.

New Reimbursement Policy

We have formalized our Bundled Services Reimbursement Policy (Commercial and Medicare), which applies to both EmblemHealth and ConnectiCare. There are no changes to how claims are being paid. New codes are being added March 1, 2023. See the policy’s Revision History for the new codes.

Updated Reimbursement Policies

The following reimbursement policies are being updated. See their revision histories for effective dates and applicable changes:

• Home Health Care Services Reimbursement Policy
• EmblemHealth Laboratory/Venipuncture Reimbursement Policy
• Preventive Lists:
  • EmblemHealth-Commercial
  • ConnectiCare-Commercial
  • EmblemHealth-Medicare
  • ConnectiCare-Medicare
• Ambulatory Surgical Grouper Policy: ConnectiCare updated the ASC Grouper Policy to include new codes effective Jan. 1, 2023. Ambulatory surgical groupers will be paid according to surgical contracted rates when billed with revenue codes 360 or 490. If surgical services are billed with revenue codes other than 360 or 490 and the claims contain charges for anesthesia and/or recovery room, claims will be paid according to the surgical contracted rates unless otherwise negotiated.

As a followup to our story in last month’s newsletter, starting Jan. 1, 2023, we introduced the following updates to our reimbursement policies:

• A new Foot Care Services and Nail Debridement Reimbursement Policy (commercial, Medicare, and Medicaid) for both EmblemHealth and ConnectiCare.
• The EmblemHealth and ConnectiCare Modifier Reference Policy will align with Centers for Medicare & Medicaid Services’ (CMS) 10% payment reduction for claims submitted with modifiers FX (use of traditional x-ray film rather than digital radiography) and FY (x-rays taken using computed radiography technology/cassette-based imaging).
• ConnectiCare’s Commercial Preventive Services List will be updated with State of Connecticut’s new breast/ovarian cancer mandate criteria.
• The Coding Edits reimbursement policies will include new edits applicable to modifier JW (drug amount discarded/not administered to any patient) (EmblemHealth | ConnectiCare).
• A new From/To Date Span Policy, Facility and Professional
  (Commercial, Medicare, and Medicaid) Reimbursement Policy is being implemented to ensure we are only paying claims with properly documented dates of service. If the date of service submitted for a procedure is out of the “From” and “To” date calendar range or not in the correct format, claims will be denied.

Starting Jan. 1, 2023, the following changes will apply to our EmblemHealth and ConnectiCare Medicare Advantage plan (MAPD) and Prescription Drug Plan (PDP) members’ cost-sharing responsibilities:

• Members will pay no more than $35 for each one-month (30-day) supply of covered insulin. Members with extra help will pay less.
• Members will pay $0 for most covered Part D vaccines, including shingles vaccine.

See full stories (EmblemHealth | ConnectiCare)

See revision history for applicable changes and their effective dates for these Pharmacy Medical Preauthorization Lists:

• EmblemHealth
• ConnectiCare

The Federal Drug Administration (FDA) encourages use of this infographic to talk with your patients about biologics and biosimilars. The FDA also offers free accredited continuing education courses for health care providers. See full announcements Biosimilars: Are They the Same Quality? (EmblemHealth | ConnectiCare) for the list of classes.