Welcome to Office Matters!

Tuesday, November 1, 2016

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Agenda

Welcome & Introductions

- Judith Feld, M.D., Medical Director, Provider Engagement & Practice Innovation

The New Provider Engagement Team

- Diane Parrish, Director, Provider Relations & Engagement

Health Care Reform 2.0 Payment Reform

- Roberta Rifkin, Senior Vice President, Government Programs and Government Affairs

2017 Commercial Product Offerings

- Alice Schurr, Product Management Manager

Agenda

Wellness Minute

- Sheila Goldberg, Corporate Wellness Specialist

2017 Medicare Product Offerings

- Laryssa M. Domagala, Mgr., Sales Development, Training & Regulatory Adherence

2017 Pharmacy & Formulary Changes

- Sheila Arquette, Director, Pharmacy Services

Independent Health Subject Matter Experts Availability

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Questions?

Please submit your questions in one of the following ways:

- Question cards are provided at each table to write your questions.

- Email your questions to melissa.masse@IndependentHealth.com

- Our subject matter experts in key areas are available in the lobby following the presentations.

- Today’s Q&A’s will be shared soon at IndependentHealth.com and in the November edition of Scope.

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Office Matters

The New Provider Engagement Team

- Diane Parrish, Director, Provider Relations & Engagement

Provider Engagement – The Team

Physician Engagement Specialists

•Amy Vitale Anthony Mungen

•Frank Charles Bogusha Thornton

Provider Relations Advocates and Correspondence Team

•Amy Anderson- Manager Melissa Masse

•Adam Stopa Katherin Long

•Kathi Rosenhahn Renee Patterson

•Lori Cassidy

Coding Integrity Specialists

•Leah Mateczun- Manager Elaine Clouden

•Bryan Sinclair Cindy Smith

•Shirley Blesnuk Elaine Kostek

Provider Engagement

Inbound Call Center Provider Relations

Physician Engagement Specialists

Coding Education

What do look for next?

Facelift of website

Renewed focus on SCOPE

newsletter

Provider scorecards

Physician Engagement

Specialist Visits

Education opportunity

Office Matters

New Secure Provider

Portal

Office Matters

Health Care Reform 2.0 Payment Reform

- Roberta Rifkin, Senior Vice President, Government Programs and Government Affairs

Health Care Reform 2.0 Payment Reform

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“As economists have often pointed out, we pay doctors

for quantity, not quality. As they point out less often, we

also pay them as individuals, rather than as members of a

team working together for their patients. Both practices

have made for serious problems.” Atul Gawande

Healthcare spending makes up a quarter of all federal spending

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The sources of health spending

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Paying for quantity

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Paying for Quality – the Shift to Value Based Payment

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• Reward health care providers with incentive payments for the quality of care they deliver to patients

• Supports the triple aim:

Better Care for

Individuals

Better Health for Populations

Lower Cost

Two Primary Drivers towards VBP at the Federal Level

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The ACA was signed on March 23, 2010

MACRA was signed on April 16, 2015

Affordable Care Act (ACA)

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• Increased Access to Insurance via – Individual & Employer Mandates – Health Insurance Exchanges – Medicaid Expansion

• Established the Centers for Medicare and Medicaid Innovation (CMMI) – Develop, test, and implement new

payment and delivery models – Tasked with reducing costs while

preserving or enhancing quality of care ACA didn’t include physician payment

Access

Quality

Cost

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Medicare Access and CHIP Reauthorization Act

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• Replaces the Stabilization Growth Rate formula that established yearly targets for physician payment.

– Balanced Budget Act 1997

– If expenditures for a year exceeded the target the update for the next year would be reduced

– Intended to control yearly growth

• Medicare Access and CHIP Reauthorization Act (MACRA)

– Quality Payment Program (QPP)

– Stabilizes payment and shifts providers to payment based on quality

MACRA- Two Payment Tracks

Track 1: Merit-Based Incentive Payment System (MIPS)

• Consolidates current

Medicare quality programs

into one.

• Earn positive of negative

payment adjustments based

on performance.

Quality

Advancing Care Information

Improvement Activities

Track 2: Advanced Alternative Payment Models (AAPM)

• Participants can receive a 5 percent bonus payment for sufficient participation in an AAPM.

• The participation threshold will increase each year of the program.

MACRA- Who it applies to

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• MACRA applies to eligible clinicians who bill Medicare more than $30,000 a year or provide care for more than 100 Medicare patients a year

• Eligible clinicians for 2017

– Physician

– Physician assistant

– Nurse practitioner

– Clinical nurse specialist

– Certified registered nurse anesthetist

• Payment in 2019 will be based on performance in 2017

CMS MACRA Resources

• CMS provides summaries, toolkits, a quality measure “shopping cart” and webinars

• Critical to stay informed

• Medical specialty organizations are also a helpful resource

• https://qpp.cms.gov/

From FFS to Value-Based - Medicare’s Goal

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Medicaid Reform

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“It is of compelling public importance that the State conduct a fundamental restructuring of its Medicaid program to achieve measurable improvement in health outcomes, sustainable cost control and a more efficient administrative structure.“ - Governor Andrew M. Cuomo, January 5, 2011

NYS MEDICAID REFORM

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Two primary components:

• Medicaid Redesign Team (MRT)

– Managed Care for All

– Began 2011, will continue through 2019 until all benefits and populations are carved-in

• Delivery System Reform Incentive Payment (DSRIP)

– Delivery system reform

– Payment reform

New York State Medicaid Redesign Team Selected as a 2015 Finalist

for the Innovations in American Government Award

Delivery System Reform Incentive Payment - DSRIP

CMS approved waiver program which provides the State with $8Billion to reinvest in to the Medicaid system

• Keeping people out of hospitals, specifically reducing preventable admissions and readmissions & ED use by 25% over five years (2015-2020)

• Moving to value based payment (VBP)

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VBP LEVELS

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By waiver Year 5 (2020), MCOs expected to employ non-fee-for-service payment systems that reward value over volume for at least 90% of their provider payments for Medicaid

• Level 0 is not considered as a payment reform program

• Plans that do not move to level 1 VBP or higher will not be eligible for enhanced payment

Payment Reform – It is a team sport!

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VBP – PAYMENT TIME LINE

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Office Matters

2017 Commercial Product Offering

- Alice Schurr, Product Management Manager

2017 Individual Marketplace Products

Platinum

Standard Platinum

Flex Fit Platinum

Choice Plus Platinum

Silver

Standard Silver

iDirect Silver Copay HSAQ

Choice Plus Silver HSAQ - Off Marketplace Only

Max Silver - Off Marketplace Only

Gold

Standard Gold

iDirect Gold Copay

Choice Plus Gold

Bronze

Standard Bronze

iDirect Bronze HSAQ

Catastrophic

Standard Catastrophic

Individual Market

2017 Individual Product Changes

– Change iDirect Silver Coinsurance to iDirect Silver Copay Health Savings Account Qualified

– Max Silver changed from an Exclusive Provider Organization (EPO) to a Point of Service (POS)

– All Standard Plans and Catastrophic will have Point of Enrollment (POE) Wellness Benefit (Health Extras $250 or Nutrition)

– Adult vision exam added to non-Standard plans

– Change Choice Plus Silver HSAQ from a coinsurance based product to a new copayment based product named Choice Plus Silver copay HSAQ

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2017 Small Group Products

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Platinum

Standard Platinum

Flex Fit Platinum

Choice Plus Platinum

iDirect Platinum

Passport Plan Platinum

Gold

Standard Gold

Healthy New York

iDirect Gold Copay

Choice Plus Gold

iDirect Gold Copay HSAQ

iDirect Gold

NY PA Gold

Passport Plan Gold

Max Gold

Bronze

Standard Bronze

iDirect Bronze HSAQ

Passport Plan Bronze HSAQ

iDirect Bronze MV

Silver

Standard Silver

iDirect Silver Copay HSAQ

iDirect Silver Copay

iDirect Silver Coinsurance HSAQ

Passport Plan Silver HSAQ

NYPA Silver HSAQ

Choice Plus Silver HSAQ - Off Marketplace Only

Max Silver - Off Marketplace Only

2017 Small Group Products

– New plan for 2017 - iDirect Bronze MV HSA Qualified

– Healthy NY – adding Point of Service benefit

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2017 Large Group Products

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Point of Service

Encompass Plus

FlexFit

FlexFit Select

EPO

Easy Access

High Performing Network

Choice Plus Copay

Choice Plus Coinsurance

National Coverage

Traditional

Passport Plan

High Deductible Plans

iDirect

Evolve

Choice Plus

2017 Benefit Changes

Individual and Small Group

Inpatient Habilitation Services Physical, Speech and Occupational

- Change from not covered to instead covered at 60 days per condition per plan year on all products

- This benefit is new for 2017

Habilitation* Services Physical, Speech and Occupational Therapy

- 60 visits per condition, per plan year combined for all therapies on Standard plans

* Habilitation Services: Health care services that help a person keep, learn or improve skills and functioning for daily living. Habilitative Services include the management of limitations and disabilities, including services or programs that help maintain or prevent deterioration in physical, cognitive, or behavioral function. These services consist of physical therapy, occupational therapy and speech therapy.

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2017 Benefit Changes

Individual and Small Group

Outpatient Radiation (Individual plans only)

- Apply coinsurance to the facility and physician component of radiation therapy at freestanding and specialist offices

Individual, Small and Large Group

Compression Stockings

- Limited to 12 units (single stocking) per plan year

Mental Health Parity

- Limited changes to reduce the Mental Health member liability to comply with Mental Health Parity testing

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2017 Benefit Changes

Individual, Small and Large Group

Diabetic Supplies

- Diabetic test strips: Apply a 100-unit limit for a 30 day supply dispensed by DME vendors (Supplies dispensed at pharmacies currently imposes the 100 test strip limit)

Mandates

- Breast cancer screening and diagnostic testing

- Opioid abuse mandate

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Mandates – Individual, Small and Large Groups

Breast Cancer Screening and Diagnostic Procedures – Opioid Abuse

– Expands coverage of screenings and diagnostic testing for breast cancer detection by eliminating member liability for diagnostic imaging for breast cancer.

– January 1, 2017, health plans will be required to provide immediate access without prior authorization, to a 5-day emergency supply of FDA-approved medication for the treatment of substance abuse disorder, including medication for opioid withdrawal and overdose reversal.

– Coverage may be subject to copayments, coinsurance, and deductibles, but it must be proportional to the amount received by the patient.

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Mandates – Individual, Small and Large Groups

- January 1, 2017, health plans will be required to cover unlimited,

medically-necessary inpatient treatment, without prior authorization, for members who have a substance abuse disorder.

- This includes an initial 14 days of inpatient treatment in facilities located in New York State, OASAS-certified and within the plan’s network. A member would only be responsible for the applicable copayments under their plan.

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Office Matters

Wellness Minute

- Sheila Goldberg, Corporate Wellness Specialist

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Wellness 101

- The Center for Disease Control recommends that adults get a minimum of 150 minutes of exercise per week.

- Research shows that those who are a physically active tend to live longer and healthier lives.

- Moderate to Intense activity plays a significant preventative role in cardiovascular disease, obesity, type 2 diabetes and some cancers.

- Research suggests that interrupting time spent sitting with light activities such as standing, stretching or walking, is important for preventing the negative health consequences of sitting too much.

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Workspace Workouts

Get up and get moving! Please Stand!!

Toe Flexion/Extension Leg Extension

Hamstring Stretch Hip Stretch

Arm/Shoulder Circles Side Stretch

Back Stretch Cardio Activities

- Walking

- Running

- Cycling

- Rowing

- Swimming

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Office Matters

2017 Medicare Product Offerings

- Laryssa M. Domagala, Mgr., Sales Development, Training & Regulatory Adherence

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2017 Medicare Annual Open Enrollment

- Members have from October 15 - December 7

to select a new plan for January 2017

- Current members have received plan

information specific to their plan (October 1)

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2017 Product Line Up

Independent Health’s 2017 individual product portfolio consists of four existing plans and one new plan:

- Independent Health’s Medicare Passport Advantage PPO

- Encompass 65 Basic HMO

- Encompass 65 Core (new for 2017)

- Encompass 65 with no prescription coverage

- Family Choice Special Needs Plan.

Three plans will no longer be available as of January 1, 2017:

- Independent Health’s Network Advantage HMO.

- Encompass Select HMO/POS

- Encompass 65 Essential HMO/POS

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All 2017 Medicare Advantage Plans

All plans for 2017 are full network plans

– No tailored network for PCPs

– No tiered inpatient hospital copayments

– All plans are available in all 8 WNY Counties

The Pharmacy benefit includes our full pharmacy network

– We do not have a preferred pharmacy network

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Introducing our new Premier Wellness Package

Vision - covers routine eye exams and an eyewear allowance

Preventive Dental - includes routine cleanings, exams and X-rays

Gym Membership - at any participating facility in Western New York

New Hearing Aid Benefit - hearing aid evaluation exam and purchase

New Enhanced Annual Wellness Visit

- A comprehensive annual wellness visit with your doctor that includes a detailed exam and conversation to create a personalized care plan

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Enhanced Annual Visit (EAV)

- Continuing in 2017 as a member benefit.

- Able to proactively discuss this as a benefit to further engage members in seeing their PCP.

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Overall Plan Changes – Individual MA Plans

All HMO plans will be pure HMO. This means:

– Out of network services will be limited to Worldwide Emergency Care, Urgently Needed Care and Renal Dialysis.

– Communication is planned for members who currently use out of network benefits for more than Urgent/ Emergent care in 2016.

– Out of Plan Referral/ Authorization is still in place for services that can’t be performed in our network. Requires Prior Authorization.

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Overall Plan Changes

- Outpatient Surgery Copayment will be split based on location of service

- The copayment will be lower if the out patient surgery is performed in a “free-standing ambulatory surgery center” vs. a hospital based surgery

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Clarification of Existing Benefits

HMO – Out of Pocket maximum

$3,400 (No Rx plan) or $6,700 (other HMO plan) maximum out of pocket member cost on HMO plans

– Out Of Pocket maximum = the total of all the Members cost share for Medicare covered Medical services

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Staying the same in 2017

Observation Status- copay will mirror outpatient surgery

– Member should be notified of status in the hospital

– Can be a retro review to determine if inpatient stay should have been observation status

– ER is waived if admitted to Observation

– Observation is waived if admitted IP

– Highest copay would apply

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Benefits at a glance for 2017

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New Plan: Encompass 65 Core HMO

- This is an HMO plan with Part D

- Available in all 8 counties of WNY

- It has our full provider network

- All Hospitals

- All PCPs

- All Pharmacies

- Lowest monthly premium plan (with Part D)- $65 per month

- Includes our Premier Wellness Package

- Pharmacy benefit includes a $200 deductible on tier 3,4,5

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2017 Rx Benefit Structure

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Plan Name 2016 Rx Benefit 2017 Rx Benefit

E65 Basic $4/$10/$47/$75/33% No Deductible

$4/$10/$47/50%/33%

Passport Advtg. $4/$12/$45/$90/33% No Rx Deductible

$4/$12/$45/45%/33%

E65 Core $200 Deductible on Tiers 3,4,5

$10/$20/$47/48%/29%

Notifying members of formulary changes

Members impacted by negative formulary changes to their medications

have been notified.

For drugs being removed from the formulary, or drugs going up in cost, generic alternatives are listed within the notice.

– How to request a coverage determination and contact information is also included.

– Two waves of letters are being sent 10/10 and 11/1

Members impacted by more than 4 formulary changes are contacted by our MTM team for additional help with selecting new formulary medications.

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Transition and Continuity of Care

We provide a temporary supply anytime within the first 90 days of the member’s enrollment.

Retail setting

– the one-time temporary supply is for at least 30 days of medication, unless the prescription is written for less than 30 days.

– In this case Independent Health allows multiple fills to provide up to a total of 30 days of medication.

After the 30 day supply, we will not pay for the drugs unless a coverage determination has been submitted and approved.

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Office Matters

2017 Pharmacy & Formulary Changes

- Sheila Arquette, Director, Pharmacy Services

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2017 Formulary Changes

2017 formulary changes are minimal.

– We continue to focus on removing multi-source brands (MSB) from formularies

– We continue to evaluate pricing data identifying high cost generic drugs with therapeutically equivalent, cost effective alternatives

– We continue to monitor and identify significant manufacturer driven brand drug price increases (i.e. Zegerid and Glumetza)

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Medicare Updates

What is the definition of a Part D covered drug and why does it matter?

A Part D covered drug is defined as:

- A drug that may be dispensed only upon a prescription-CMS interprets this as meaning a drug that is recognized by the FDA as a prescribed drug requiring “Rx only” on its label

- A biological product

- Insulin

- Medical supplies associated with the delivery of insulin

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Medicare Updates

- A vaccine licensed under section 351 of the Public Health Service Act and its administration.

- CMS considers it best practice for Part D sponsors to consider the proper listing of a drug product with the FDA as part of determining which drugs to cover. The FDA has a Comprehensive NDC Structured Product Labeling Data Elements file (NSDE) which is used to determine at the point- of- sale (POS) which products can be covered.

- Drug must be included in the Part D sponsor’s formulary or coverage authorized as a result of the coverage determinations or appeal process and obtained at a network pharmacy.

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Medicare Updates

- For drugs submitted and approved by the FDA under a new drug application (NDA) or a biologics license application, the manufacturer must participate in the Medicare Coverage Gap discount program.

- May be covered under Part D and is not otherwise excluded from coverage (i.e., bulk compounding powders):

- Extemporaneous Compounds-only compounds that contain at least one ingredient that independently meets the definition of a Part D drug

- Extemporaneous Compounds-only compounds that do not contain any ingredients covered under Part B as prescribed and dispensed or administered.

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Medicare Updates

- Prescribed for a Medically-Accepted Indication which means the indication for which it is FDA approved or the use of which is supported by one or more citations in the recognized compendia.

- For anticancer chemotherapeutic regimens the definition of medically accepted indication includes the Part B definition and utilizing Part B compendia and peer reviewed medical literature.

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Medicare Updates

- Drugs FDA approved for sale in the United States except in the event of a

drug shortage and certain importation and regulatory requirements apply.

- Drug is not a classified as a DESI drug.

- Drug is not otherwise excluded from coverage.

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Medicare Updates

Excluded Drugs

- Agents used for anorexia, weight loss or weight gain

- Agents when used to promote fertility

- Agents used for cosmetic purposes or hair growth

- Agents when used for the symptomatic relief of cough and colds

- Prescription MOV and mineral products, except prenatal and fluoride preparations

- Nonprescription drugs

- Agents used for the treatment of sexual or erectile dysfunction

- Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee

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Medicare Updates

Why is this important and how may it impact you?

Other areas of focus and why you may hear from the Pharmacy Department:

– M.E.D. (morphine equivalent dose monitoring)

– B vs D determinations

– Beers drug management

– Transition

– Part D Medicare Star Measures

• Statin Adherence

• Diabetes drug adherence

• ACE/ARB

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Office Matters

Our Independent Health subject matter experts are now available in the lobby for your questions.

Thank you for attending Office Matters