January 2025: New Provider Portal enhancements; Cultural competency training and resources

Mentoring prepares the next generation of healthcare leaders to thrive

Mentorship is so important for mentees and mentors. While it creates an opportunity for mentors to give back, it’s also a reminder that a lot can be learned from others. In recognition of National Mentoring Month, let’s look at how nursing mentors work to create a better future in healthcare.

“Preceptors live at the intersections of education and practice, and of the present and the future. They practice at the point where theoretical learning meets reality and where the gap between current and needed knowledge and expertise gets filled,” Beth Tamplet Ulrich wrote in “Mastering Precepting: A Nurse’s Handbook for Success.” 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:

• About the Qualified Medicare Beneficiary (QMB) program
• New Provider Portal enhancements are live
• Webinar and resources: Cultural competency training for providers
• ACO spotlight: Provider’s role in improving quality measures
• Annual code and rate updates
• Risk Score Management team transitioning to Optum from PopHealthCare
• Flexible Services is now part of the HRSN Supplemental Services Program
• New for 2025: The Medicare Prescription Payment Plan helps members manage monthly drug costs
• Update to multiple procedure reduction rule on January 1, 2025
• Medicare Advantage FQHC billing guidelines
• Hospital inpatient utilization report
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• Formulary updates
  
  

About the Qualified Medicare Beneficiary (QMB) program

What is the Qualified Medicare Beneficiary (QMB) program?

The Qualified Medicare Beneficiary (QMB) program is one of four Medicare Savings Programs for dual eligible beneficiaries that are funded by the federal government and managed by state Medicaid agencies. The QMB program is designed to help people who are eligible for Medicare and Medicaid (Dual eligible), and meet certain income requirements, pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments.

Federal law prohibits all Medicare FFS and Medicare Advantage providers and suppliers from charging individuals enrolled in the QMB program for Medicare cost sharing for covered Parts A and B services. Providers who do not follow the QMB billing prohibition are in violation of their contract with Mass General Brigham Health Plan and may be subject to sanctions.

Program information:

• Cost sharing: Medicare beneficiaries enrolled in the QMB program have no legal obligation to pay Medicare Part A or Part B deductibles, coinsurance, or copays for any Medicare-covered items and services. Medicare providers, suppliers, and pharmacies cannot balance bill QMB eligible individuals for any Medicare Part A or Part B services.
  • In some cases, providers may bill the State Medicaid program and to receive a small Medicaid co-payment.
  • All Medicare and Medicaid payments received for services rendered to individuals in the QMB program are considered payment in full.
• Prescriptions: QMB billing protections apply only to those prescriptions covered under Part B.  Under Part D, QMBs may be subjected to copays; however, the low-income subsidy (LIS) program, or “Extra Help,” will limit the amount a QMB program participant pays for Part D prescriptions. For more information, please refer to the Medicare Learning Network (MLN): https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1128.pdf

Identifying individuals participating in the QMB program: 

Mass General Brigham Health Plan has ways to help you identify members in the QMB Program.

• On the weekly Remittance Advice, claims for members in the program will be flagged to indicate calculated plan cost sharing (copayment or coinsurance) that should not be collected from or billed to the member.
• In the Provider Portal
• Through submission of a 271 and receipt of the 272 reply
• Call MGBHP’s Customer or Provider Services <add phone numbers/hours of operation>
• The state Medicaid program and Medicare may also have resources to help providers identify program participants

What providers should do:

• • Do not bill the member for any cost sharing or balance bill amounts
    • If you have previously billed a QMB participant for cost sharing, stop billing immediately
         ○ If you collected cost sharing from a program participant, refund them immediately
         ○ If you have initiated collection efforts against a member who is an eligible QMB, stop collection services immediately
• Refer to the MLN article to learn more about billing the state Medicaid program for unpaid Medicare cost sharing
• • Most importantly, continue to provide members with access to care and services.

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.

Webinar and resources: Cultural competency training for providers

Visit Health Equity Resources on the Provider Resources page at https://massgeneralbrighamhealthplan.org/providers/resources to explore free online training options regarding Cultural Competency.  There is also an opportunity to earn credits depending on the program.  According to the training offered by the Department of Health and Human Services, “the e-learning program will equip you with the knowledge, skills, and awareness to best serve all patients, regardless of cultural or linguistic background."

In addition, there is a webinar opportunity regarding Limited English Proficiency using the link provided below. Limited English Proficiency (LEP) is a term used to define a person’s narrow ability to read, write, and/or speak English. Approximately 8% of the United States’ population (accounting for 25.7 million people) have LEP. Of this amount, 853,374 reside within the state of Massachusetts. Studies show that LEP patients often receive a lower quality of care when compared to fluent/native English speakers. The most common reasons for lower quality of care among LEP patients include communication barriers, cultural differences, and bias. Due to this, LEP is associated with increased medical errors, lower patient adherence, worse clinical outcomes, and poor patient satisfaction. Despite these disparities among LEP patients, there are ways in which clinicians can mitigate these effects and provide high-quality care for patients experiencing LEP. The video linked below is an educational webinar which gives insight on the steps clinicians can take to improve healthcare delivery for LEP patients. We hope you find this webinar helpful.

Watch now: https://www.qualityinteractions.com/hubfs/Share/MGB/QI_LEP_Webinar.mp4

ACO spotlight: Provider’s role in improving quality measures

At Mass General Brigham Health Plan, the Quality Department spearheads performance improvement for the ACO Quality Measures that are part of the MassHealth AQEIP and the National Committee of Quality Assurance (NCQA).

For the January edition, the Quality Department has provided HEDIS Tip Sheets for the following quality measures: Childhood Immunization Status (CIS), Immunizations for Adolescents (IMA), Statin Therapy for Patients with Diabetes (SPD), and Statin Therapy for Patients with Cardiovascular Disease (SPC).

As a provider there are many opportunities to impact HEDIS® measures. This includes educating parents and caregivers on the importance of childhood and adolescent vaccinations, scheduling follow-up appointments, coordinating care, using correct diagnosis and procedure codes, and educating patients on the importance of taking their medications regularly and as prescribed.

Click on the links below to see Provider Tips on how you can help improve the Quality Measures.

Annual code and rate updates

Mass General Brigham Health Plan reviews its fee schedules quarterly, to ensure that they are current, comprehensive, and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes to supplement the fees already on the fee schedule.
Consistent with prior years, Mass General Brigham Health Plan will update its Commercial/PPO physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2025.  Rate updates to existing CPT and HCPCS codes will occur on July 1, 2025.

With a few exceptions, Mass General Brigham Health Plan will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) and MassHealth fee schedules, adjusted to achieve the contracted level of reimbursement.

Commercial/PPO physician fee schedules

• Mass General Brigham Health Plan will continue to base physician reimbursement on CMS RVU’s.
• Mass General Brigham Health Plan will continue to base drug, vaccine, and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.

Commercial/PPO outpatient fee schedules

• Consistent with prior years, reimbursement will be based on a combination of outpatient, ancillary, and surgical fee schedules.
• Mass General Brigham Health Plan will continue to base drug, vaccine, and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.

Medicaid ACO fee schedules

• Mass General Brigham Health Plan will continue to base physician reimbursement on MassHealth published rates.
• Consistent with prior years, Mass General Brigham Health Plan will update its Medicaid physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2025.  Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate changes from MassHealth.

Medicare Advantage fee schedules

• Mass General Brigham Health Plan will update its Medicare Advantage inpatient, outpatient, ancillary, professional, DME, and drug fee schedules/pricers to incorporate new codes and update rates, effective January 1, 2025.  

Risk Score Management team transitioning to Optum from PopHealthCare

The Mass General Brigham Health Plan Risk Score Management team is transitioning to Optum from PopHealthCare for chart retrieval risk adjustment audits. Please note that our Quality team will continue to use Cotiviti. 

Flexible Services is now part of the HRSN Supplemental Services Program

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 (MPP).

The MPP 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 MPP and participation is voluntary. Members must voluntarily opt into the MPP 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 MPP 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 MPP 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 MPP. However, if they would like the MPP to be active January 1, they must opt into the program during the annual election period.

Members may opt out or leave the MPP at any time by contacting the health or drug plan. Leaving the MPP won't 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 MPP. 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 MPP, 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/plans/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.

Medicare Advantage FQHC billing guidelines

It has come to our attention that some Federally Qualified Health Centers (FQHCs) are not submitting bills for Medicare Advantage in compliance with CMS billing guidelines and Mass General Brigham Health Plan billing instructions. Kindly review the guides below and reach out to Provider Relations if you have any questions:

 Medicare Advantage FQHC/RHC Billing Guide

Provider Payment Guidelines: Community Health Centers   

Hospital inpatient utilization report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register here.

Medical policy updates

Thirteen (13) medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. View a summary of the updates here. 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 January 2025 here. 

View the coverage summary for new codes here.

View the coverage summary for MGB ACO and commercial 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.