December 2024: Popular provider resources; diabetes prevention program for members

What caregivers need to know about working with health insurance

Caregivers often step in to manage personal affairs, including health insurance. In recognition of National Caregiver’s Month, and to honor the work of caregivers everywhere, let’s look at how a caregiver can work better with a patient’s health plan.

Continue reading to learn more from Lauren Domings, Customer Service Supervisor at Mass General Brigham Health Plan, for some insight on how to make the best use of a patient’s coverage. Read the full article.

Contact

MGBHP Provider Service Team assists our Provider Community with the following inquiries:
•    General questions around provider participation status
•    Member benefits
•    Claim request for review/appeals
•    Authorization requirements/escalations
•    Medical drug specialties 
•    Other inquiries related to MGBHP policies and procedures  
Phone:  855-444-4647
Email: HealthPlanProvidersService@mgb.org 

MGBHP Provider Relations works in partnership with provider offices to build and maintain positive working relationships and respond to the needs of contracted providers and assist with any training and education. Provider Relations can also assist with escalations. 
Email: HealthPlanProvRelations@mgb.org 

Provider Portal: Register for the portal to complete the following tasks:

•   Benefits and cost sharing 
•   Claims status
•   Member eligibility
•   PCP changes
•   Authorization submission
•   EOP
•   And more

Register and access the portal here: https://Provider.MGBHP.org/ 

In this issue:

• Win a $100 gift card - Confirm your directory info and next available appointments
• New Provider Portal enhancements are live
• Provider resource center: Popular forms and tools for your practice
• Path to Lifestyle Change: Diabetes prevention program for members
• Fall Spring Regional Provider Meeting review and spring invite coming soon
• Flexible Services transitioning to Health-Related Social Needs (HRSN) framework
• New for 2025: The Medicare Prescription Payment Plan helps members manage monthly drug costs
• Update to multiple procedure reduction rule on January 1, 2025
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• Formulary updates

Win a $100 gift card - Confirm your directory info and next available appointments

Please take a few minutes to complete both of the following brief forms by the end of December and you'll be automatically entered into our drawing to win a $100 gift card. 

1. Provider Directory Accuracy: Let us know if your information is accurate by completing this form.  
2. Future Appointment Access: Let us know about your next available appointments by completing this form.

New Provider Portal enhancements are live

We’re excited to announce you can now submit claims and claims reviews in the Provider Portal. These enhancements launched on November 14. Please review the instructions for submitting a request for claim review. A video walkthrough of these steps will be available in the coming weeks. When submitting a claim or claim review, a transaction number confirming receipt of submission will be available and providers can track the status of a submission within the Provider Portal. Please note, a claim review form must be completed and attached to the online claim review submission.

If you need assistance with the Provider Portal, please contact HealthPlanprweb@mgb.org.

Provider resource center: Popular forms and tools for your practice

We’ve made it easy for you to do business with Mass General Brigham Health Plan by organizing popular forms and resources on one resource page. Here's a sample of what's available:

Clinical resources:

• Medical policies – Medical policies provide you with the coverage criteria for specified conditions. You can find more information on the utilization management (UM) decision making process and how to obtain UM criteria in the Provider Manual.
• Clinical contact information – Clinical staff is available at 855-444-4647 Monday-Friday (8:30 a.m. - 5 p.m.). After hour coverage is available after 5 p.m. on weekdays and on the weekends.
• Care management programs – You can get more information on specific programs and how you can refer a member into one of our care management programs. Providers can refer by emailing: HealthPlanCareManagement@mgb.org 
• Tobacco cessation – For members who are trying to quit tobacco, we offer a tobacco cessation program run by our Certified Tobacco Treatment Specialists. Providers can refer by email: HealthPlanQuitSmoking@mgb.org 
• Health coaching – Health coaching is available for members trying to improve eating habits, increase their physical activity, manage weight and decrease stress. Our health coaches have all completed the rigorous Wellcoaches® school of coaching training program. Providers can refer by emailing: HealthPlanHealthandWellness@mgb.org 

Provider Manuals

• Commercial Provider manual
• Mass General Brigham ACO Provider manual
• Medicare Advantage Provider manual

The Provider Manuals include important information on how you can support your patient. Topics in the Provider Manuals include:

• Quality Improvement Program
• Utilization management decision-making – This includes information regarding our decision-making process and procedures. We do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service, nor do we provide financial incentives to UM decision-makers to encourage decisions that result in under-utilization.
• Credentialing and re-credentialing processes
• Member rights & responsibilities
• Practitioner rights & responsibilities
• Interpreter services

Pharmacy benefit program

Our website gives you the most up-to-date information about our Pharmacy programs, covered medications, and the current medical necessity criteria. Pharmacy programs include:

• Excluded medication – A medication that is considered to be excluded from the pharmacy benefit.
• Pharmacy & Therapeutics Committee – This Committee is chaired by the Medical Director responsible for pharmacy and is composed of practicing pharmacists and practicing providers with varying specialties, including behavioral health, internal medicine, and pediatrics. It meets regularly throughout the year, no less frequently than quarterly.
• Prior authorization – A pharmacy program that limits access to a medication by establishing criteria for appropriate use of a medication. These criteria must be met and documentation sent to us before the medication will be covered. Prior authorization is also required for exception to our mandatory generic medication pharmacy benefit.
• Quantity limit – A pharmacy program that limits the number of units per time period for a specific medication based on recommended doses.
• Step therapy – A pharmacy program that allows patients who meet criteria to have coverage for their prescription adjudicate without review based on available medication history.
• Mandatory generic – A pharmacy program that requires a trial of an FDA approved generic substitution for a brand name medication, if it is available.
• Tier placement - A pharmacy program that places medications in one of six co-payment tiers for benefit plans with a six-tier pharmacy benefit.
• Therapeutic interchange/substitution –A pharmacy program that involves the dispensing of a chemically different drug, considered therapeutically equivalent, i.e., will achieve the same outcome, in place of a drug originally prescribed by a physician. The drugs are not generically equivalent. Therapeutic substitutions are done in accordance with procedures and protocols set up and approved by physicians in advance. Therefore, the pharmacist would not have to seek the prescribing physician's approval for each interchange.

Visit the Provider resource center 

Path to Lifestyle Change: Diabetes prevention program for members

In recognition of National Diabetes Month, we are spotlighting our diabetes prevention program, Path to Lifestyle Change. The program is delivered remotely to patients with prediabetes and at high risk of developing type 2 diabetes. It is a covered benefit for members in our fully insured commercial plans who are eligible based on a hemoglobin A1c level in the prediabetes range or a high score on the diabetes risk test. Members can call 617-724-0653 or email pathtolifestylechange@mgh.harvard.edu to start the enrollment process. Check out the flyer here.

Fall Spring Regional Provider Meeting review and spring invite coming soon

On behalf of the Provider Relations team, thank you to those who joined us at our fall Regional Provider Meeting on November 11. We are preparing for our spring event and are excited to integrate the valuable feedback we received from our attendees. Here is what attendees had to say about the event

• "Best presentation by any health plan I have participated in."
• "The set up for the meeting was perfect"
• "Great meeting, helpful information"

Keep an eye out for our spring Regional Provider Meeting invite going out in early 2025. 

Meet the Provider Relations team:

Flexible Services transitioning to Health-Related Social Needs (HRSN) framework

Effective January 1, 2025, MassHealth members enrolled in the Mass General Brigham Accountable Care Organization (ACO) may be able to receive additional housing and/or nutrition support through the MassHealth Health Related Social Needs (HRSN) Supplemental Services program. This framework will combine existing Community Support Programs, (Community Support for Homeless Individuals (CSP-HI), Community Support Program for Individuals with Justice Involvement (CSP-JI), Community Support Program Tenancy Preservation Program (CSP-TPP), and the Flexible Services Program (FSP) into a new Supplemental Services construction.

HRSN Supplemental Services are a standard set of services developed by MassHealth. Each HRSN Supplemental Service has specific programmatic eligibility that a member must meet in order to qualify. For complete HRSN Supplemental Services eligibility, please see the Supplemental Service Manuals found on the HRSN webpage for additional information.  View frequently asked questions (FAQs).

Mass General Brigham Health Plan anticipates offering the following HRSN Supplemental Services to eligible members effective 1/1/2025.

For additional general questions, please contact the Mass General Brigham’s ACO HRSN central team at mgbhrsn@mgb.org.

New for 2025: The Medicare Prescription Payment Plan helps members manage monthly drug costs

Starting January 1, 2025, members can choose to spread out their covered Part D out-of-pocket prescription drug costs over the calendar year. The Inflation Reduction Act requires all Medicare prescription drug plans, including standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage, to offer members the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy. This new payment option is known as the Medicare Prescription Payment Plan (M3P).

The M3P doesn’t lower members covered Part D drug costs or save money. However, it may be helpful for members to spread their payments for covered Part D drug costs across the remaining months of the calendar year. There’s no cost to members to participate in the M3P and participation is voluntary. Members must voluntarily opt into the M3P to participate. To maximize this payment option, members should opt-in to this payment option prior to filling their prescriptions.

Members who may benefit from the M3P if:

• They have high covered Part D drug costs early in the plan year.
• They will exceed the $2,000 annual out-of-pocket maximum Medicare Part D drug cost amount for 2025 before September.
• They want to spread their covered Part D drug costs throughout the rest of the year.

Members who may not benefit from the M3P:

• Low yearly out-of-pocket covered Part D drug costs (<$2,000 per year).
• Members receiving or eligible for Extra Help from Medicare.
• Members receiving or eligible for a Medicare Savings Program.
• Members receiving help paying for drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.

Members must voluntarily renew their participation or opt into the M3P each year. Members may opt in during the annual election period beginning in October or may wait until the plan year to opt into the M3P. However, if they would like the M3P to be active January 1, they must opt into the program during the annual election period.

Members may opt out or leave the M3P at any time by contacting the health or drug plan. Leaving the M3P will affect their Medicare drug coverage and other Medicare benefits.

If a member does not pay their Medicare Prescription Payment Plan bill, they’ll be removed from the M3P. Members are required to pay the amount owed but will not pay any interest or fees, even if the payment is late. If a member is removed from the M3P, they are still enrolled in their Medicare health or drug plan.

For more information about the program, please see the following resources:

• https://massgeneralbrighamadvantage.org/mppp 
• https://www.medicare.gov/prescription-payment-plan
• https://www.medicare.gov/publications/12211-whats-the-medicare-prescription-payment-plan.pdf

Update to multiple procedure reduction rule on January 1, 2025

Beginning January 1, 2025, Mass General Brigham Health Plan is updating its multiple procedure reduction rule to more appropriately align with CMS and industry standards. When multiple surgical services are performed in the same operative session, the procedure with the highest RVU will be reimbursed at 100% of the allowed amount and all subsequent, lower-RVU valued procedures, will be reduced per the Plan’s Modifiers Provider Payment Guidelines, unless otherwise specified in the provider’s contract.

Medical policy updates

Thirteen (13) medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to MGBHP.org.

For more information or to download our medical policies, go to https://www.MGBHP.org/providers/medical-policies and select the policy under the medical policy listings.

Drug code and code updates

View code updates for December 2024 here. 

Medicare drug and prior auth updates for 2025

View Medicare Part B and Part D updates here. 

Formulary updates

View the formulary updates here.