SCOPE | Provider Update
December 2024
Clinical Matters
HIV testing should be a routine part of health care
HIV testing must be offered at least once as a routine part of health care to all patients age 13 or older receiving primary care services at an outpatient clinic or primary care services..
HIV testing must be offered at least once as a routine part of health care to all patients age 13 or older receiving primary care services at an outpatient clinic or primary care services from a physician, physician assistant, nurse practitioner or midwife.
IMPORTANT points to remember:
- NYS Public Health Law mandates the offer of HIV testing to all patients age 13 or older.
- The offer of HIV testing is most effective when it is presented as a clinical recommendation of the health care provider.
- The provider must document the offer of HIV testing in the patient medical record.
- Facilitate early prenatal care with universal opt-out HIV testing at the first prenatal visit and repeat HIV testing in the third trimester.
The health care provider must provide information about HIV orally, in writing, through signage or in any other patient-friendly audio-visual format. Placing the NYSDOH HIV testing clinic poster in a visible location or providing patients with the NYSDOH patient brochure on HIV testing are simple ways of conveying this information to patients.
Information to be provided to the patient prior to HIV testing before conducting diagnostic HIV testing.
The key points of information that must be provided are:
- HIV testing is voluntary, and all HIV test results are confidential (private);
- HIV can be transmitted through unprotected sex, sharing needles, childbirth or breastfeeding;
- Treatment for HIV is very effective, has few or no side effects and may involve taking just one pill once a day;
- Partners can keep each other safe by knowing their HIV status and getting HIV treatment or taking HIV pre-exposure prophylaxis (PrEP).
- Not sharing needles and practicing safer sex will help protect against HIV, hepatitis C and other STDs.
- It is illegal to discriminate against a person because of their HIV status and services are available to help address discrimination;
- Anonymous HIV testing (without giving your name) is available at certain public testing sites;
- HIV testing is a routine part of health care, but patients have the right to decline an HIV test. Testing should not be performed if the patient objects.
Information and Resources
When testing indicates a diagnosis of HIV infection, the person ordering HIV testing or their representative must provide the patient with the final interpretation of diagnostic testing, and, with the patient’s consent, schedule an appointment for follow-up HIV medical care. This must be documented in the patient’s medical record.
For more information and resources, please visit
CDC issues new recommendations on pneumococcal vaccinations
Data suggests that beginning at 50 years, adults have an increased risk of pneumococcal infections, which can lead to pneumonia, meningitis, and bloodstream infections.
The Centers for Disease Control and Prevention (CDC) has updated its recommendations for pneumococcal vaccinations, aiming to enhance protection against pneumococcal disease across various age groups and risk categories. The recommendation released on October 23, 2024, lowered the age for pneumococcal vaccination from 65 to 50 years old.
Data suggests that beginning at age 50 years, adults have an increased risk of pneumococcal infections, which can lead to serious infections like pneumonia, meningitis, and bloodstream infections. This is regardless of the presence or absence of risk factors. Being aware of these changes is crucial for healthcare providers to ensure optimal patient care and adherence to the latest guidelines.
Key recommendations
Children under 5 years:
- Routine Vaccination: Administer a 4-dose series of either PCV15 or PCV20 at 2, 4, 6, and 12 to 15 months of age.
- Catch-Up Vaccination: For children who miss their shots or start the series late, follow the CDC’s catch-up schedule to ensure they receive the necessary doses.
Adults 50 years and older:
- Routine Vaccination: All adults aged 50 and older should receive either PCV15, PCV20, or PCV21.
- If PCV15 is used, it should be followed by a dose of PPSV23 at least one year later or 8 weeks later in adults with immunocompromised conditions, cochlear implant or cerebrospinal fluid leak.
- Shared Clinical Decision-Making: For adults 65 and older, vaccination with PCV20 or PCV21 can be considered based on individual health status and risk factors.
- They can get either PCV20 or PCV21 if they’ve received both PCV13 (at any age) and PPSV23 (at or after 65 years of age). It is recommended to wait at least five years between the PCV13 or PPSV23 and PCV20 or PCV21.
Adults 19 to 50 years with certain risk factors:
- Vaccination Indications: Adults in this age group with underlying conditions such as diabetes, chronic liver disease, or immunocompromising conditions should receive pneumococcal vaccines.
- Vaccine Options: PCV15 followed by PPSV23, or PCV20 alone, are recommended based on the patient’s vaccination history and risk profile.
Implementation tools
PneumoRecs VaxAdvisor: A free app provided by the CDC to help healthcare providers determine the appropriate pneumococcal vaccines for their patients. Available for iOS, Android, and as a web-based tool. Here is the link to the web-based tool.
Job Aids: The CDC offers various job aids to simplify the interpretation of vaccination schedules and assist in clinical decision-making.
For more information and resources, visit:
MediSource, MediSource Connect and Essential Plans to cover in-home sleeps studies as of December 1
At-home sleep tests (HSTs), also known as Unattended Sleep Studies or Home Sleep Apnea Tests (HSAT), are used to help diagnose sleep disordered breathing conditions in the home setting when medically appropriate.
According to the NYS Medicaid August 2024 Update, New York State Medicaid Managed Care plans, including Independent Health’s MediSource, MediSource Connect and New York Essential Plan will cover in-home sleep studies beginning December 1, 2024.
Independent Health will require prior authorization for code 95800 and will follow the New York State Medicaid coverage criteria. The ordering provider must meet the standards outlined below:
Criteria:
- Member must be 18 and over. Please note that Child Health Plus is excluded from coverage.
- Coverage is limited to members who would experience difficulty traveling to a sleep lab for a lab-based sleep test (polysomnography) due to mobility issues [e.g., members who need assistance with ambulation or use a Durable Medical Equipment (DME) to ambulate, such as a wheelchair or a walker] as long as the home sleep study is a medically appropriate alternative member.
- For members who meet the above coverage criteria, healthcare providers should use their clinical judgment to determine if an HST is a medically appropriate alternative to a lab-based sleep test (polysomnography).
- Additionally, home sleep study raw data must be reviewed and interpreted by a Sleep Medicine specialist who is either board-certified or board-eligible in Sleep Medicine.
It is imperative that health care providers use good clinical judgment when determining if a home sleep study is a medically appropriate alternative to a lab-based sleep test (polysomnography).
Limitations:
- Home sleep studies can only be billed once per year. If a repeat home sleep study is needed before the one-year mark, persuasive medical evidence will be required.
Repeat studies may be indicated for the following situations:
- If the first study was technically inadequate due to equipment failure.
- If the member did not know how to operate the HST equipment correctly or did not sleep for a sufficient amount of time to allow a clinical diagnosis.
The following must be documented in the medical records of the patient:
- Documentation of informed consent by the patient.
- Documentation supporting the medical necessity for sleep testing must be maintained in the clinical file of the ordering physician.
- Documentation of patient history, physical exam, and healthcare provider assessment that prompted the need for an HST must be in the file prior to HST.
- Documentation of the HST outcome/test results.
Billing instructions
- Orders for sleep testing are limited to Sleep Medicine specialists who are fellowship-trained and board-certified/board-eligible and may include family medicine physicians, internal medicine physicians, pediatricians, psychiatrists, neurologists, pulmonologists, and otolaryngologists. See billing instructions below:
- Do not report Current Procedure Code (CPT) code "95800", in conjunction with CPT codes "93041" through "93227", "93228", "93229", "93268" through "93272", "95801", "95803", and "95806".
- Watchpat must be billed as CPT code "95800".
- If a sleep study is performed for less than six hours, it should be billed with modifier "52".
- Bundled under the one rate includes cost of equipment, the assessment, and interpreting results.
Reimbursement:
CPT Code | Modifier | Description | NYS Medicaid Rate |
---|---|---|---|
95800 | N/A | Sleep Study, unattended, simultaneous recordings; heart rate, oxygen saturation, respiratory analysis (e.g. by airflow or peripheral arterial tone), and sleep time. | $117.08 |
95800 | TC | Physician provides the test only. | $84.68 |
95800 | 26 | Physician only interprets the results. | $32.40 |
GLP-1 coverage policy for weight loss changing as of Jan. 1, 2025
Pre-authorization requirements for commercial products will focus on individuals with severe obesity and comorbid conditions as of Jan. 1.
Recognizing the importance of a doctor’s expertise to find the right approach to manage weight loss goals, Independent Health has a weight-loss medication policy for our commercial plan members that requires preauthorization for GLP-1s.
We continue to track growing utilization and costs of GLP-1 medications used for weight loss. Based on the expected growth of GLP-1 utilization, and to be consistent with other health plans, we will update the policy requirements for GLP-1 coverage and modify the formularies for commercial products (except for the Federal Employees Health Benefits Plan, or FEHB, which has its own requirements).
Therefore, to help manage costs and improve value for our members, Independent Health is making changes to the preauthorization process and formulary in 2025 for commercial products and the Essential Plan:
- Policy update effective Jan. 1, 2025: Among other changes to the policy, the prior authorization criteria will include a BMI of 40kg/m2 or greater in the presence of at least two comorbid conditions, including but not limited to coronary heart disease, atherosclerotic diseases, hypertension, dyslipidemia osteoarthritis, sleep apnea, polycystic ovary syndrome), or BMI of 30kg/m2 or greater with established cardiovascular disease.
The policy effective Jan. 1, 2025, has additional changes, including weight loss and other requirements; it is important to review the policy for these updates. The policy will be posted by Dec. 1, 2024.
- Formulary changes effective March 1, 2025: For your awareness, Wegovy, Saxenda and Zepbound will become non-formulary for Drug Formularies I, II, III, and the Essential Plan Formulary. Contrave will be the only formulary weight loss product. Please note, the above policy will apply to formulary exception requests.
We will post this policy 30 days before March 1, 2025.
Additional information
- We continue to require individuals to complete a six-month formalized weight management program that was added to the policy for September 2024.
- Members who are currently taking these medications will be re-assessed when their authorization is due for renewal. Re-authorization will be based on the new policy; for example, individuals whose BMI is less than 40 might not obtain authorization.
The coverage policy is consistent with other commercial health plans locally and across the country.
We recognize that some members have successfully maintained a healthier weight with these medications; however, we are very concerned at the cost of these medications and the financial impact they have on premiums and health care in general, so we have had to make the difficult decision to focus these weight loss medications on our members with severe obesity who have a higher risk for obesity-related complications and comorbidities.
Clinical Practice Guidelines reviewed and updated
The Quality Performance Committee has reviewed and approved updates to guidelines and has updated links to resources.
Independent Health's Quality Performance Committee has reviewed and approved the Clinical Practice Guidelines (CPG’s), which have been updated where necessary. Changes include adoption of the following guidelines:
- Adopted ADHD CDC guideline Clinical Care of ADHD | Attention-Deficit / Hyperactivity Disorder (ADHD) | CDC, May 2024
- Adopted Depression APA guideline Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts (apa.org), Sept 2024
The following website links have been updated:
- Smoking Cessation intervention guideline link updated: Smoking and Tobacco Use | Smoking and Tobacco Use | CDC, 2024
- Diabetes Standards of Care: Standards of Care in Diabetes | American Diabetes Association, 2024
- Kidney Disease: American Journal of Kidney Diseases (ajkd.org), 2024
- Child and Adolescent Immunization Schedule by Age (Addendum updated June 27, 2024) | Vaccines & Immunizations | CDC , 2024
- Opioids for Chronic Pain - Guidelines for Prescribing Opioids for Chronic Pain 2022 CDC Clinical Practice Guideline at a Glance | Overdose Prevention | CDC
- Hepatitis Clinical Screening and Diagnosis for Hepatitis C | Hepatitis C | CDC, Dec 2023
The updated clinical practice guidelines are posted in the provider portal under the Policies and Guidelines tab.
Office Matters
Cost sharing waived on Individual On-Exchange plans for diabetes-related services, pregnant/postpartum individuals
Certain services may have no cost share for eligible individuals includes office visits, prescription drugs and other services beginning 1/1/25.
Beginning January 1, 2025, Qualified Health Plans available on the New York State of Health (NYSOH) Official Online Marketplace will waive the in-network cost-sharing such as deductibles, copayments, and coinsurance for Qualified Health Plan (QHP) enrollees who have a primary diagnosis of diabetes, and for outpatient maternity care services.
The objective of reducing plan members’ out-of-pocket costs is to improve their ability to manage diabetes by improving access to recommended care, lowering the likelihood of unnecessary hospitalizations, and improving overall health.
For QHPs, this program will be available to individuals who are enrolled in an Individual On Exchange, standard and/or nonstandard plan, except for catastrophic plans.
Diabetes cost share waiver
This program applies to specific items and services and includes medical care, prescription drugs, supplies, and diagnostics, related to the primary diagnosis of diabetes.
- What this means to providers: if the individual has a primary care visit and the primary diagnosis is diabetes, the provider must not charge the member the copay.
View the full list of $0 services for these plans here.
Maternity cost share waiver
For pregnancy and postpartum enrollees in Qualified Health Plans (QHPs), NY State of Health will cover the in-network cost-sharing such as deductibles, copayments, and coinsurance for most services.
Removing cost-sharing barriers for this population will allow individuals to obtain needed care including medical services, lab/x-ray services and supplies, and prenatal testing.
For QHPs, this program will be available to pregnant members who are enrolled in an Individual on exchange, standard and/or nonstandard plan, except for catastrophic plans.
This initiative will cover cost-sharing for all diagnosis and services for individuals during pregnancy and through 12 month postpartum, with exception to the services listed here: cost share waivers for individuals here.
- What this means to providers: the provider must not charge the member the copay during pregnancy and through 12 months postpartum.
Cost-sharing will still apply to physician, nurse practitioner and midwife services for delivery as well as inpatient hospital and birthing center services for delivery.
For additional reference, the full description of diabetic and maternity services that will have no cost share is outlined on the member’s contract amendment.
Check WNYHEALTHeNET for eligibility
Please be sure to check Additional Info under Plan Details. The message for an eligible member will state: “Member may be eligible for a NY State Diabetic/Maternity Cost Share Waiver plan (excludes Standard Catastrophic), please call for specific benefit information.”
Surescripts Real-Time Prescription Benefit feature available Dec. 9
Real-Time Prescription Benefit through Surescripts, which allows provider practices to view medication costs and therapeutic alternatives through their Electronic Health Record (EHR) systems.
Independent Health and our pharmacy benefit management affiliate, Pharmacy Benefit Dimensions, have arranged Real-Time Prescription Benefit through Surescripts, which allows provider practices to view medication costs and therapeutic alternatives through their Electronic Health Record (EHR) systems.
Having this information at prescribers’ fingertips will help ensure that cost is less of a barrier to patients taking their prescribed medications.
Here’s how it works
Real-Time Prescription Benefit embeds Independent Health member benefit information into a provider office’s prescribing workflow. It gives the prescriber access to up-to-date pharmacy benefit details, price information and viable alternatives.
Surescripts Real-Time Prescription Benefit helps enhance medication adherence and enables the prescriber to:
- View formulary options and actual price information. This will initially include our Medicare line of business and will include commercial and self-funded products in the future.
- See step therapy, age and quantity limits, and prior-authorization alerts, which can help to reduce calls back to the patient, and get them started on the medication sooner.
How to get started
Surescripts will be ready to introduce this on Independent Health’s participating practices’ EHRs by December 9, 2024.
Please contact your EHR and confirm your EHR supports Surescripts and also to discuss the next steps to access this solution.
Upcoming member campaigns to encourage our members to take greater control of their health
Throughout the year, the Quality Management and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.
State Member Incentive Program Campaigns
Independent Health State members will have until December 31, 2024 to complete various preventive care visits and screenings to receive an incentive for the following programs:
- Gaps-in-Care Program - State members can earn gift cards for completing various preventive care tests and screenings included in the program.
- Non-Utilizer Program - State members with 7 or more months of continuous enrollment without a claim on file are eligible to earn a gift card for completing an annual well visit.
- Maternity Management Program - State members can earn gift cards for completing a prenatal visit during the first 12 weeks of pregnancy and postpartum visit within 11 weeks after delivery.
- Timeframe: August through December 31, 2024
Metabolic Monitoring for Children and Adolescents on Antipsychotics
The Independent Health Behavioral Health and Pediatric Case Management departments will outreach to parents or guardians of members under the age of 13 who have been prescribed an antipsychotic medication but have not received metabolic monitoring (glucose and cholesterol testing). The Case Manager will provide the parent/guardian with education on the importance of metabolic screening for the child and encourage follow-up conversation with the provider regarding testing.
- Outreach method: Outbound telephone call campaign
- Target members: Commercial and Medicaid members under the age of 13 who are prescribed antipsychotics and have not received metabolic monitoring (glucose and cholesterol testing).
- Timeframe: September through December 31, 2024
Gap in Care Reminder Calls
Independent Health’s Member Services team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a script to complete the screening.
- Target members: Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings.
- Timeframe: Call campaign began in August and will run throughout 2024
Social Determinants of Health Screening
This telephonic outreach campaign will engage targeted members in a conversation around screening for social determinants of health to identify any needs the member has for food, housing, and/or transportation. If a need is identified, Independent Health will assist the member in making a connection to a community resource to address the need.
- Outreach method: Outbound telephone call campaign
- Target members: Medicare members identified with social risk factors including those with low-income subsidy or dual enrollment in Medicaid; HARP members starting SUD treatment.
- Timeframe: Call campaign began in June and will run throughout 2024
Osteoporosis Management in Woman Who Had a Fracture (OMW) Member Outreach
Independent Health’s Case and Disease Management Facilitator will outreach telephonically to Medicare members who fall into the Osteoporosis Management in Woman Who Had a Fracture (OMW) measure.
- Target population: The OMW measure focuses on females 67 to 85 years of age who had a fracture and have six months following the fracture to close the gap by having a bone density scan, filling a script for an osteoporosis medication, or receiving an injection for osteoporosis treatment.
Independent Health’s Case and Disease Management Facilitator will contact members to discuss the member’s fracture, provide education on fractures and falls prevention, and discuss options for gap closure.
The Case and Disease Management Facilitator will discuss the option of an in-home heel ultrasound with Stall Senior Medical (SSM). If the member is interested, the Case and Disease Management Facilitator will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.
The Case and Disease Management Facilitator will also discuss other options for gap closure, depending on the member’s preference, and refer back to the member’s PCP. Each call will be individualized based on the member’s needs.
- Timeframe: This outreach is on-going. Monthly, new members are called that fall into the measure.
Eye Exam for Patients with Diabetes (EED) Member Outreach
Independent Health will be facilitating outreach telephonically to Medicare members who have a gap in care for the Eye Exam for Patients with Diabetes (EED) measure.
- Target population: Medicare members with a diagnosis of Diabetes (type 1 or 2) who have not had a retinal eye exam. An eye exam in the year prior must be negative for any type of retinopathy. If year prior eye exam is positive, then an eye exam in the current measurement year is needed.
- Outreach method: Outbound telephone call campaign.
- Medicare: Independent Health will call members and discuss the option of an in-home eye exam with Stall Senior Medical (SSM). If the member is interested, Independent Health will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.
- Timeframe: End of October through December 2024
Pharmacy Updates
Formulary and Policy Changes
Stay up-to-date on Independent Health's pharmacy policies and formulary updates.
Drug Policy Changes
The policy changes for the Fourth Quarter of 2024 are now available online. You must be logged in to the provider portal to view the changes.
Search for and view the most current versions of all Independent Health’s drug policies when logged in to our provider portal.
Prime Therapeutics (formerly Magellan Rx) reviews select specialty drug prior authorization requests on Independent Health’s behalf. View Prime Therapeutics policies for the drugs that they review.
Drug Formulary Changes
View the formulary changes for the Fourth Quarter of 2024.
Access Independent Health's 2024 and 2025 drug formularies.
To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.
Spotlight
Top Takeaways this Month
All of us at Independent Health wish our participating providers and Scope readers a wonderful holiday season!
CVS will no longer be a participating pharmacy as of Jan. 1, 2025 for all lines of business. Patients will have to switch prescriptions and their pharmacy by then.
Keep track of all important Department of Health Public Health Bulletins here.
Compliance Alert: Each practice MUST submit its 2024 Fraud, Waste, Abuse and Cultural Competency Awareness attestation by Dec. 31. Get details on the process here.