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NEW HAMPSHIRE MEDICAID CARE MANAGEMENT PROGRAMWell SenseSM Health Plan is the business name in New Hampshire for Boston Medical Center Health Plan, Inc.
This is a provider communication - Not for distribution to consumers.
WELL SENSE HEALTH PLAN: LEADER IN MEDICAID, COMMITMENT TO QUALITY Well Sense Health Plan is the business name in New Hampshire for Boston Medical Center Health Plan, Inc.
An experienced, not-for-profit, provider-sponsored Medicaid managed care organization
Founded in 1997 by Boston Medical Center
Currently serving more than 250,000 members in the Medicaid (MassHealth), Commonwealth Care and commercial plans
Maintained Excellent Accreditation from the National Committee for Quality Assurance (NCQA) for its Medicaid
plan since its initial accreditation in 2009
The Massachusetts Medicaid product (BMC HealthNet Plan) is ranked #3 nationally among Medicaid plans
according to NCQA’s Medicaid Health Insurance Plan Rankings, 2011-2012
BMC HealthNet Plan’s cost efficiency is in the range of the top 25% most efficient Medicaid managed care plans
(fiscal year ending 9/30/11)
HARVARD PILGRIM HEALTH CARE: INDUSTRY LEADER IN NEW HAMPSHIRE #1 ranked private health plan in America according to NCQA’s Private Health Insurance Plan Rankings, 2011-2012
Only private health plan in the nation to be named #1 for member satisfaction and quality of care for eight
consecutive years*
Harvard Pilgrim Health Care of New England, Harvard Pilgrim’s New Hampshire affiliate, is the top ranked private
plan in New Hampshire, according to NCQA’s Private Health Insurance Plan Rankings, 2011-2012
*NCQA’s Private Health Insurance Plan Rankings, 2011-2012. NCQA’s Health Insurance Plan Rankings 2010-11 – Private. U.S.News/NCQA America’s Best Health Insurance Plans 2005-2009 (annual). America’s Best Health Insurance Plans is a trademark of U.S.News & World Report. NCQA The State of Health Care Quality 2004.
WHY ARE WE COLLABORATING? Harvard Pilgrim has a longstanding commitment to serving the citizens of New Hampshire through commercial offerings, our Foundation and as the insurer for New Hampshire Healthy Kids. The partnership with Well Sense Health Plan will enable Harvard Pilgrim to bring value to even more of the state’s residents
Harvard Pilgrim’s network contracting strengths as a commercial insurer and its knowledge of the New Hampshire market are brought together with Well Sense Health Plan’s strength in serving Medicaid members
Through this partnership, Harvard Pilgrim will develop and maintain a statewide New Hampshire Medicaid network of acute care hospitals, primary care providers, specialists and many ancillary providers for Well Sense Health Plan. In addition, Well Sense Health Plan will work with its other partners to build its New Hampshire network of behavioral health care, pharmacy and durable medical equipment providers.
WELL SENSE HEALTH PLAN – EXPERIENCE, NH PRESENCE Experience collaborating with providers across Massachusetts
15 years of experience with new and growing programs for the underserved, with significant Medicaid managed care experience and associated infrastructure
Successful care management programs
Well Sense Health Plan will have an ongoing local presence in New Hampshire with an office in Manchester. Functions in our Manchester office will include:
o Care Management
o Provider Relations
o Community Outreach
o Medical Management
KEY FEATURES FOR PROVIDERS Accurate, timely claim processing standards Over 98% of claims paid within 30 days Average turn around time of claims = 9.4 days Responsive Provider Relations model and high standards of clinical professionalism Forecasted to achieve an administrative expense efficiency ratio of less than 7% which is among the lowest in the nation Benchmarking data indicate Medicaid managed care organizations incurred a median administrative efficiency ratio of 8.0% in calendar year 2010
PROVIDER-BASED INCENTIVE PROGRAMSTo support the delivery of quality care to our New Hampshire Medicaid members, Well Sense Health Plan will establish a quality incentive program for participating primary care physicians and provider organizations based on NCQA HEDIS metrics and/or other nationally recognized quality metrics.
OVER 98%of claims paid within
30 DAYS
AVERAGEclaim turn around
9.4 DAYS
MEMBER MANAGEMENTWell Sense Health Plan is committed to giving all members the information and tools needed to better understand their special health conditions, so they can maintain healthy lifestyles. Care management programs are free for members and their families, and oversee a broad spectrum of conditions. Care managers assist members with understanding the benefits and community resources available to them, contact members by phone to check on their health, and help coordinate care with the members’ doctors and other healthcare providers.
Members who struggle with serious and complicated health conditions can also be enrolled in Well Sense Health Plan’s Care Management Select program. This program offers the features above, plus:
More frequent check-ins from a care manager, including in-person visits, as needed. Enhanced coordination of care with the member’s healthcare providers
Our Nurse Advice Line is also available to all members. This 24-hour nurse line, accessible by a toll-free number, puts members in touch with specially trained nurses to assist in determining proper levels of care for health needs.
HIGHLIGHTING SUNNY STARTThe Sunny Start program helps moms and babies get the care they need during and after pregnancy. Members who enroll in the program get help from care management staff, including:
Customized care planning by Well Sense Health Plan care coordinators for low risk pregnancies, or registered nurses for high risk pregnancies Access to registered nurses skilled in obstetrics and newborn care for any needs relating to safe and healthy pregnancies Help with determining eligibility and applying for WIC Assistance and reminder calls related to postpartum care Education on preventing pre-term labor and delivery Help with finding community resources for housing, legal assistance, shelter and clothing
HEDIS® PERFORMANCESuccessful care management programs have led BMC HealthNet Plan (our Massachusetts health plan) to be in the top 10% of all Medicaid HMO plans* in these HEDIS performance measures:
Breast, cervical and chlamydia screening rates Lead screening rates in children Appropriate testing for children with pharyngitis Controlling high blood pressure HbA1c, retinal and nephropathy screening among diabetics Follow-up care for children on ADHD medications Follow-up after hospitalization for mental illness Timeliness of prenatal care Well care visits among children and adolescents Child access (ages 2-19) to primary care
*Based on data submitted by over 130 Medicaid HMO plans to the National Committee for Quality Assurance (NCQA) and published in the NCQA HEDIS 2011 Quality Compass. This data submitted by NCQA for BMC HealthNet Plan’s Massachusetts’ Medicaid HMO population.
BEHAVIORAL HEALTH PROGRAM COMPONENTSWell Sense Health Plan has partnered with Beacon Health Strategies (Beacon) to deliver quality behavioral health management for the New Hampshire Medicaid Managed Care program. At the very heart of Beacon’s approach to implementing a behavioral health system and corresponding payment reform is a “whole person” approach to providing care, which recognizes the relationship between medical, behavioral and social needs, and the need for unique partnerships within the community. Beacon is committed to forging relationships to develop an integrative transparent clinical model of care with the community mental health centers.
DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND MEDICAL SUPPLIESNorthwood, which is URAC accredited in health utilization management and claims processing, will manage the prior authorizations and claims payment of most durable medical equipment, orthotics, prosthetics and medical supplies. Well Sense Health Plan renders all medical necessity denial decisions and provides the required notifications.
MEDSOLUTIONSMedSolutions, Inc., a URAC accredited and NCQA certified Radiology Management company, is contracted to manage prior authorizations and medical necessity decisions for all outpatient elective Magnetic Resonance Imaging (MRI/MRA), Computed Tomography (CT), Positron Emission Tomography (PET) and Nuclear Medicine/Myocardial Perfusion Imaging (NCM/MPI) studies.
VISION BENEFITVision Service Plan (VSP) is contracted to maintain a network of providers for routine eye care and to process related claims.
NON EMERGENCY MEDICAL TRANSPORT (NEMT)Coordinated Transportation Solutions, Inc. will partner with Well Sense Health Plan to provide transportation and/or coordinate transportation requests for covered medical, behavioral health and dental services for members.
IS YOUR CHILD
OVERWEIGHT?
Well Sense Health Plan’s C
are Management Programs can help yo
u
learn about healther meal options a
nd excersize routines fo
r your child!
NEW HAMPSHIRE MEDICAID MANAGED CARE PROGRAM Our Approach to Care Management and Collaboration with Providers
Please note: In New Hampshire, Well Sense Health Plan is the business name for Boston Medical Center Health Plan, Inc. (BMCHP). The BMCHP care management programs and services described below will be implemented for our New Hampshire Medicaid members through Well Sense Health Plan.
The goal of Well Sense Health Plan’s Care Management programs is to help members regain optimum health or improved functional capability through focused support, coordination of care and services, and promotion of self-management. Care Managers work with primary care providers (PCPs), specialists and other care team members to develop member-centered plans. Our care managers promote the PCP as the member’s central care manager. Facilitating communication between members and PCPs is key. Providers often have the most updated information about their members, so if we have difficulty reaching a member, we contact PCPs, specialists and home care agencies to obtain current demographic information and elicit support for introduction of care management.
We partner with providers and state agencies to coordinate and facilitate the provision of high quality services and to ensure that services across specialties
are integrated to best meet the needs of our members. We believe that the hallmark of care management services is coordination of care, which involves comprehensive assessment and re-assessments of the member’s condition. Assessments include evaluation of functional status, current and past medical history, depression screening, and behavioral heath needs. We also perform psychosocial assessments to determine the availability of care givers, support systems, community resources, and financial needs. Outreach includes mailings, phone calls, face-to-face visits and provider site visits, when appropriate.
We look forward to working with providers during 2012-13 on payment reform plans that expand upon our first year’s quality program. Our commitment to quality is demonstrated in BMCHP having maintained Excellent Accreditation from the National Committee for Quality Assurance (NCQA) each year since our initial Accreditation in 2009.
We realize that some provider systems have their own extensive care management programs. We plan to meet with larger provider groups early in the program to understand their infrastructure, medical home experience and care management resources to determine together whether some delegated care management would be appropriate. We also plan to support providers developing medical home principles and practices, and those interested in taking on risk in the future.
Following is a summary of programs, materials and other items now in development for Well Sense Health Plan in New Hampshire. These are based on BMCHP’s experience and its current offerings to BMCHP members.
IS YOUR CHILD
OVERWEIGHT?
Well Sense Health Plan’s C
are Management Programs can help yo
u
learn about healther meal options a
nd excersize routines fo
r your child!
HAVE A HEALTHY
HEART.Well Sense Health Plan’s C
are Management Programs show you the best
ways to manage your Coronary a
rtery Disease!STOPPING SMOKING
WHEN YOU’RE PREGNANT.
Well Sense Health Plan’s Care Management Programs help you quit
smoking to give your baby a Sunny Start!
WELLNESS AND PREVENTION VIA EDUCATION We will provide our members with educational materials and information via mailings, the Internet and telephone so they can take a proactive approach to health and wellness.
Our Well Sense Health Plan member literature and outreach will stress the importance of the PCP’s role to administer or arrange for the member’s care. We will mail reminders to members about preventive care related to well child visits, immunizations, blood pressure monitoring and preventive screenings for cervical cancer and breast cancer. Physicians will receive periodic reminders about members in need of various screenings (e.g., well child visits, diabetic testing and others). Our Well Sense Health Plan website (wellsense.org, now under development) will offer a wide range of wellness topics and activities for all New Hampshire Medicaid members. (To see examples of the types of information we will offer, visit bmchp.org.) o Well Sense Health Plan website member materials will be written at reading/literacy levels that are useful to a broader member base and will be available in print upon request. Our member education condition- specific materials will be mailed to members by our care managers, as appropriate,
and many materials will be available in Spanish and other languages upon request. Access to interpreters for other languages will be available through the Well Sense Health Plan Customer Care Center. o The website will include a pharmacy tool to enable members to identify possible drug interactions with over-the-counter drugs and dietary supplements, and to provide focused education about the use of controlled substances. It will also offer information about non-pharmaceutical approaches to assist in managing pain, anxiety disorders, sleep disorders and attention deficit hyperactivity disorder. Members are encouraged to call their PCPs, but have access to a 24-hour Nurse Advice Line when needed. On the Nurse Advice Line, registered nurses advise members – based upon their symptoms – whether they should seek urgent or emergency care, contact their PCP for an office visit, or suggest how they might treat their condition at home. The Nurse Advice Line also provides access to an audio health library with information regarding a variety of common and chronic illnesses and diseases as well as activities to maintain or improve health.
CHRONIC CARE, HIGH RISK/COST AND COMPLEX CARE MANAGEMENTWell Sense Health Plan will identify child and adult members who may qualify for different levels of care management programs. This identification will occur monthly through sophisticated, disease-specific algorithms leveraging medical, behavioral health and pharmacy claims data, lab result data when available, and predictive modeling risk scores; hospital discharge review processes; referrals from our Nurse Advice Line; Health Risk Assessments; and physician referral, member self-referral, state agencies or emergency room staff. Members will be stratified according to need, based upon our detailed algorithms:
LEVEL 1 focuses on general education and mailings for identified members. This includes reminders for screenings and tests for proper management and monitoring of conditions
LEVEL 2 involves targeted disease-specific interventions to promote and increase adherence to treatment plans and social care management
LEVEL 3 involves complex care management for members requiring the most intensive and frequent interventions (social, medical and/or behavioral health)
Conditions to be managed include the following: o Pregnancy, including high risk and low risk o Diabetes o Congestive Heart Failure (CHF) o Chronic Obstructive Pulmonary Disease (COPD)
o Asthma o HIV/AIDS o Depression o High risk behavioral health conditions o Serious and persistent mental health conditions o Co-morbid substance abuse disorders o High-volume emergency department utilizers The following programs will be added in New Hampshire: Coronary Artery Disease (CAD), Obesity, Smoking Cessation for Pregnant Women, and Special Needs. We will also have two types of Transition to Home Programs for members who are discharged from a facility with the goal of ensuring member stability and appropriate post-discharge follow up in order to reduce avoidable complications and unnecessary readmissions. o Transition to Home Full Program – Members who are discharged from the acute setting after a medical stay and who have specific diagnoses which fall into the DRGs with the highest volume of readmission. They are followed for 31- 45 days based on need and receive coordination of services and medication reconciliation. Education is conducted around the discharge plan, and the member is assessed for additional services that may be required. o Transition to Home Short Program – This is for members who do not meet criteria for the Full Program. A call is made post discharge for an inpatient setting to ensure that a follow-up appointment will occur with the PCP or specialist within seven days after discharge.
[email protected] WELLSENSE.ORG
