NYS Medicaid Coverage of Pasteurized Donor Human MilkEffective July 1, 2017, MetroPlus Health Plan, will reimburse a medical facility for prescribed, medically necessary pasteurized donor human milk (PDHM) for INPATIENT use. This reimbursement will be included in the inpatient DRG payment.

In accordance with an amendment to subdivision 2 of section 365-a of the Social Services Law, inpatient use of pasteurized donor human milk (PDHM), with fortifiers as medically indicated, requires a written medical order from a licensed medical practitioner.

PDHM is covered when infants meet clinical criteria and there is a written medical order. Coverage of PDHM is for infants who are medically or physically unable to receive maternal breast milk or participate in breast feeding, or in cases where the mother is medically or physically unable to produce maternal breast milk at all or insufficient quantities, or is unable to participate in breast feeding despite optimal lactation support.

WHAT THIS MEANS TO YOU: Medical care facilities will be reimbursed for prescribed, medically necessary PDHM for infants who: • Have a documented birth weight of less than 1500

grams; or

• Have a congenital or acquired condition that places the infant at a high risk of developing necrotizing enterocolitis (NEC) and/or infection; or

• Have other qualifying condition(s) as determined by the Commissioner of Health or his/her designee.

• Place of service is the in-patient unit. • The parent or legal guardian of the recipient signs

and dates an informed consent form indicating the risk and benefits of using banked donor human breast milk.

• This benefit will be captured as part of the inpatient diagnosis related group (DRG) payments, using revenue code 220 with procedure code T2101.

FALL 2017

Flu season Is Here! All MetroPlus Members are entitled to a flu shot. Encourage your patients to get vaccinated this winter, and help us keep our members healthy.

NYS Department of Health 340 B RequirementsPer the New York State Department of Health Medicaid Update issued December, 2016, effective April 1, 2017, the NYS Department of Health intends to change the way that it identifies 340B drugs for exclusion from rebates, by relying solely on the mandated 340B claim level identifiers.The table below summarizes the claim level reporting requirements:

Claim Type Field Fee-For-Service (FFS) Managed Care (MCO)837P/8371 Modifier UD* UDNCPDP 420-DK, Submission Clarification Code (SCC) 20 20NCPDP 23-DN, Basis of Cost Determination 08*

* All Fee-For-Service (FFS) 340B claims must be submitted at acquisition cost, by invoice, inclusive of all discounts. Please note that a FFS NCPDP claim with a 20 SCC should have a corresponding 08 BCD.

SERVING NEW YORKERS FOR OVER 30 YEARS

Access and Availability StandardsMetroPlus Members must secure appointments within the following time guidelines:

Emergency Care Immediately upon presentation

Urgent Medical or Behavioral Problem Within 24 hours of request

Non-Urgent “Sick” Visit Within 48 to 72 hours of request, or as clinically indicated

Routine Non-Urgent, Preventive or Well Child Care Within 4 weeks of request

Adult Baseline or Routine Physical Within 12 weeks of enrollment

Initial PCP Office Visit (Newborns) Within 2 weeks of hospital discharge

Adult Baseline or Routine Physical for HIV SNP Members Within 4 weeks of enrollment

Initial Newborn Visit for HIV SNP Members Within 48 hours of hospital discharge

Initial Family Planning Visit Within 2 weeks of request

Initial Prenatal Visit 1st Trimester Within 3 weeks of request

Initial Prenatal Visit 2nd Trimester Within 2 weeks of request

Initial Prenatal Visit 3rd Trimester Within 1 week of request

In-Plan Behavioral Health or Substance Abuse Follow-up Visit (Pursuant to Emergency or Hospital Discharge)

Within 5 days of request, or as clinically indicated

In-Plan Non-Urgent Behavioral Health Visit Within 2 weeks of request

Specialist Referrals (Non-Urgent) Within 4 to 6 weeks of request

Health Assessments of Ability to Work Within 10 calendar days of request

Tobacco Cessation: Medication DiscussionSmoking increases the risk for serious health problems, many diseases, and death. Encouraging tobacco users to quit and supporting them is the fastest way to reduce tobacco-related diseases, death, and health care costs.

To enhance cessation rates, it is critical for health care providers to consistently identify smokers, advise them to quit, and offer evidence-based cessation treatments, such as nicotine patch, nicotine gum or lozenges, varenicline, bupropion, nicotine spray or inhalers.

The use of cessation medications is appropriate for most adult smokers, with the exception of pregnant women, light smokers (i.e. persons who smoke <5-10 cigarettes daily), and people with specific medical contraindications.

You can also use the following 3 steps to help you with your patients:Step 1: Ask. Ask the patient whether he or she smokes or uses other forms of tobacco, and document the patient’s tobacco use status in the chart or electronic health record. Step 2: Advise. Advise the patient to quit. This advice works best when delivered in a nonjudgmental tone.Step 3: Refer. Refer patients who are interested in trying to quit to the New York State Smokers’ Quitline: 1-866-NY-QUITS (1-866-697-8487) or other community counseling resources. For a list of drugs covered by MetroPlus please follow this link to the formulary:https://www.metroplus.org/member-services/formularies

Office Waiting Time StandardsPlease remember that excessive office waiting time affects the overall member satisfaction with the provider and the health plan and besides it is plainly poor costumer service. Please follow up with these standards, which are listed in our MetroPlus Provider Manual, page 20, section 2.5.3:

• Waiting room times must not exceed one (1) hour for scheduled appointments.

• Members who walk in with urgent needs must be seen within one (1) hour.

• Members who walk in with non-urgent “sick” needs must be seen within two hours or must be scheduled for an appointment to be seen within 48 to 72 hours, as clinically indicated.

Colon Cancer Screening: Alternative to ColonoscopyColonoscopy remains the gold standard when screening for colorectal cancer (CRC). However, getting patients to make the time and agree to complete CRC can sometimes be challenging. MetroPlus covers annual stool occult blood tests with high-sensitivity guaiac (HS-gFOBT) and fecal immunochemical tests (FIT-DNA). These options, when used in average-risk patients and accompanied with adequate follow-up, may provide similar reductions in mortality as compared to colonoscopy.

Other practical alternatives for CRC are flexible sigmoidoscopy and CT colonography.Regardless of the method you choose for colorectal cancer screening, the U.S. Preventive Services Task Force (USPSTF) recommends screening adults for CRC who are between 50 and 75 years of age. For people 76-85 years of age, the decision to offer a colon cancer screening test should depend on individual circumstances such as general health and prior screening history.

Accessing Clinical Practice GuidelinesThe Clinical Practice Guidelines have been updated. You can access the new guidelines on the MetroPlus Provider portal by logging in to our Provider Portal, clicking on the Quality Management tab, selecting “Preventive Clinical Guidelines” from the list, and clicking on “Clinical Practice Guidelines.”

HOS: Improving or Maintaining Physical & Mental HealthImproving or maintaining physical and mental health are a part of the Health Outcome Survey (HOS). These measures are triple weighted in the Star Ratings. HOS assesses the ability of a Medicare Advantage Organization (MAO) to maintain or improve the physical and mental health of its members over time with help from the member’s provider. It is a longitudinal survey administered each spring to a random sample of members and the same group is resurveyed after two years to see if the member is better, the same, or worse. Providers should discuss and encourage adults (65+) to improve & maintain their physical health by starting or increasing physical activity (with exercise suitable for each patient). Providers should also discuss behavioral health treatment options with adults (65+) experiencing behavioral health symptoms.

After-Hours Protocol ReminderPCPs and OB/GYNs are required to ensure that members have access to services 24 hours a day, 7 days a week. This can be accomplished with an after-hours contact number where a live person can be reached, and on-Call Providers must return all phone calls within 30 minutes.To provide this contact number to MetroPlus, email networkrelations@metroplus.org.

2017 Provider Satisfaction Survey

MetroPlus is again conducting a Provider Satisfaction Survey to gauge your level of satisfaction with the network, provider services, and other areas of importance. Surveys have been mailed, so please complete yours as soon as you receive it. Your feedback gives MetroPlus valuable information to help us serve you and our members better.

160 Water Street, 3rd Floor, New York, NY 10038

Changes to your demographic informationNotify MetroPlus of any changes to your demographic information (address, phone number, etc.) by calling your Provider Service Representative. You should also notify MetroPlus if you leave or join a new practice. Changes can also be faxed in writing on office letterhead directly to MetroPlus at 212.908.8885. You can also call 1.800.303.9626 with changes.

MetroPlus compliance hotline

MetroPlus has its own Compliance Hotline, 1.888.245.7247. You may call this line to report suspected fraud or abuse, possible illegal activities and questionable activity.

You may choose to give your name or you may report anonymously.

SERVING NEW YORKERS FOR OVER 30 YEARSEditor: Elizabeth Colombo