November 2024: Join our Quality Program Committee; healthy eating magazine for families

Living with diabetes: Guidance towards a healthier life

According to the U.S. Centers for Disease Control and Prevention (CDC), more than 38 million people in the United States are living with diabetes. To learn more about prevention and care, we chatted with Diabetes Nurse Care Manager Elizabeth D’Urbano, RN, CDCES, CCM. She’s been with Mass General Brigham Health Plan for more than eight years and specializes in diabetes management.

“Diabetes is a very manageable condition,” D’Urbano said. “For anyone newly diagnosed with type 2 diabetes, you may even be able to reverse your diabetes through significant changes in diet and physical activity.” 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:

• Flexible Services transitioning to Health-Related Social Needs (HRSN) framework
• Join our Quality Program Committee to help improve care quality and effectiveness
• Strategies for communicating with families about the pediatric flu vaccine
• Report: Language needs of Medicaid membership population
• New for 2025: The Medicare Prescription Payment Plan helps members manage monthly drug costs
• Free online forum on substance use disorders with CME available
• Important update regarding Steward Health Care
• Win a $100 gift card - Confirm your directory info and next available appointments
• Improving call wait times
• Home health authorization update
• ACO spotlight: New healthy eating magazine for kids and families
• Update to multiple procedure reduction rule on January 1, 2025
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• Formulary updates

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

Effective January 1, 2025, the Flexible Services Program will transition into a Health-Related Social Needs (HRSN) framework and will be eligible for MassHealth members enrolled in the Mass General Brigham ACO who meet specific eligibility criteria.

Similar to the Flexible Services Program, the HRSN framework will be designed to address HRSN and will provide non-medical services aimed at improving health outcomes by addressing non-medical factors that can influence a person’s overall well-being, such as housing and nutrition.

This new framework will provide an array of housing and nutrition services to better cater to a wide range of our Mass General Brigham ACO members. The HRSN Supplemental Service Manuals and supporting HRSN documentation is available on the Mass.gov HRSN webpage. The following documents are available on the webpage: 

• HRSN Supplemental Services Service Manual Definitions
• HRSN Supplemental Services Nutrition Service Manual
• HRSN Supplemental Services Housing Service Manual
• HRSN Supplemental Services Fee Schedule
• HRSN Supplemental Services Criteria Guidance

Join our Quality Program Committee to help improve care quality and effectiveness

Mass General Brigham Health Plan is seeking provider membership (specifically clinically active MDs, DOs, NPs, and PAs) in general practice or specialty practice, for its Quality Program Committee (QPC). We are seeking providers to share their expertise on topics that will ensure the quality and effectiveness of the care delivered to its members including all lines of business.  Committee members have the opportunity to weigh in on a variety of health plan topics including:

• Network adequacy;
• Utilization Management and Medical Necessity Procedures;
• Member experience and satisfaction; and
• Identifying and addressing potential health care disparities and inequities.

The QPC meets virtually on the third Wednesday every other month for 90 minutes. 

The meeting dates for the rest of 2024 are:

• Wednesday, December 18, 7:30 - 9:00 a.m.

If you are interested in joining the QPC, please contact Elaine Alden at ealden@mgb.org indicating your interest and we will reach out with information on the next steps regarding your participation. Some providers may qualify to earn $300 per meeting. Please feel free to contact us with any questions regarding your eligibility for this and/or any other questions you may have about the committee.

We appreciate the opportunity to collaborate with our provider network and thank you for the care you provide our members.

Report: Language needs of Medicaid membership population

Mass General Brigham Health Plan analyzed language needs for the Medicaid (ACO) membership population. Based on the data, the most prevalent languages spoken by Medicaid members are Spanish, Haitian Creole, Portuguese, Arabic, Russian, Chinese (Mandarin), Vietnamese, Somali, French, and Cape Verde Creole. An analysis of language services data for Customer Service calls and medical visits found that Chinese (Mandarin), Haitian Creole, Spanish, Portuguese, and Russian were also among the top languages in which Medicaid members received language services. For more detailed information on the language needs of our Medicaid members, please view the full report.

Strategies for communicating with families about the pediatric flu vaccine

The flu vaccine is one of our best tools to protect children against serious respiratory infections. Check out our flyer for strategies on communicating with families about the importance of pediatric vaccination that includes links to video and FAQ resources from the American Academy of Pediatrics. 

Free online forum on substance use disorders with CME available

Join the Massachusetts Behavioral Health Partnership/Carelon Behavioral Health for an upcoming online forum, Advancing Treatment for Substance Use Disorders: A Comprehensive Overview for PCCs and Behavioral Health Care Providers. Learn about how to screen for SUDs, best practices around Medication-Assisted Treatment, the levels of care in Massachusetts for patients who need treatment, and resources to support patients with SUDs and the clinicians who treat them. The event is scheduled for Wednesday, November 13 from 12 - 1:30 p.m. Register now for this FREE virtual event, with CME available!

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

Important update regarding Steward Health Care

We are closely monitoring the situation with the closures of Norwood Hospital and the affiliated satellite facilities; Norwood Performance Therapy and Guild Imaging Center of Norwood Hospital, and Norwood Hospital Cancer Care Center at Foxboro.

As we continue to track new developments, we have prepared contingency plans to ensure that our members have access to the care they need.

We encourage members with concerns about the planned closures of the Steward-affiliated facilities to contact their providers. Our customer service team can also be contacted using the number on the back of the health plan ID card to help answer questions about health plan coverage and benefits.

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 November 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.

Improving call wait times

We understand there are longer than normal wait times when contacting the Provider Call Center. Our leadership team is working diligently to recruit and train additional staff to keep up with the demands in volume. We appreciate your understanding and cooperation. Please use our Provider Portal to answer routine inquiries such as benefits and cost sharing, claims status, eligibility, explanation of payments, authorization, outpatient code checker tool, and much more.  Our provider call center hours of operation are 8:00 a.m. to 4:30 p.m. Monday- Friday (closed daily from 12:00 - 12:45 p.m. and Wednesdays from 9:30 - 10:30 a.m.). You can also contact us via email at HealthPlanProvidersService@mgb.org.

Home health authorization update

Effective December 1, 2024, the way you enter homecare authorizations through the Provider Portal will be updated.  This will impact homecare authorization requests placed through the Provider Portal. Providers will have to submit a separate request for each discipline: For example, skilled nursing and physical therapy being requested at the same time for the same period, would require two separate entries through the Provider Portal.

Inputting a separate homecare authorization for each service being requested will help enhance the current provider claim and authorization process.

ACO spotlight: New healthy eating magazine for kids and families

We’re excited to partner with the Chop Chop Family to provide a new resource for your pediatric patients and their families at no cost to your practice. Research has shown children are more likely to eat healthy foods, try new foods, and develop life-long healthy eating habits when they take part in meal planning and preparation. Enter Chop Chop, an award-winning quarterly magazine, offering kid-friendly recipes, fun facts, financial literacy activities, and more. Available in English and Spanish, and in boxes of 50 copies per language. We're now accepting orders for the fall 2024 edition until November 30, 2024, while supplies last. Please limit to 200 copies per order. We will make a winter edition available starting in December. To order or request more information, please email HealthPlanHealthandWellness@mgb.org and use the subject line "Chop Chop Magazine."

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

Fourteen (14) medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to MassGeneralBrighamHealthPlan.org. The table below is a summary.

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

Drug code and code updates

View code updates for November 2024 here. 

View the new codes summary for ACO and commercial here.

View the new codes summary for Medicare Advantage here.

View coverage summary for October 2024 new codes 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.