Posts Tagged ‘Medicaid’
Sep 29th, 2011 | by
Blog post by Jim Gartner, Vice President of Pharmacy, CareSource
Beginning October 1, CareSource will provide pharmacy benefits to our members. What does this all mean? It means our members will receive even better care because we will be able to coordinate their doctor appointments, treatment options and prescription drugs. We will also be able to monitor what medications our members are receiving, if they’re taking their medication and how much they’re taking.
The biggest part of this change is that our members will no longer pay a co-pay for their medications. This will take the worry and burden away for our members who already struggle with many other financial burdens. Many of our members live every day wondering how they will pay their electric bill or buy groceries. Health care and prescription coverage should be something they don’t have to worry about.
The pharmacy team at CareSource has been gearing up for this change for months and we’re excited to provide greater coordination in the pharmacy benefit. In fact, at our All Staff meeting in July, the pharmacy team put on a little dance to remind our staff of the coming change.
We like to have fun at CareSource so everyone enjoyed the song our pharmacy team developed to educate their peers about the importance of coordinating pharmacy benefits.
I came to CareSource with a plan
To help our fellow, fellow man
Prescription drugs are not meant to abuse
It is our job to drive proper use
Pharmacy Carve In, makes it right
Pharmacy Carve In, helps the fight
Pharmacy Carve In, we are one
Here it comes, October One
You can also watch our video of us making fools of ourselves.
All joking aside, we truly believe that pharmacy carve in will be beneficial to our members’ health and well being. And we’re honored to help.
Below is some helpful information from the State of Ohio regarding the pharmacy benefit change. If you can’t find an answer to a question or need assistance, please call our member services team at 1-800-488-0134, Monday through Friday, 7:00 am to 7:00 pm.
Changes in Your Ohio Medicaid Prescription Coverage Starting October 1, 2011
These changes affect everyone in your family who gets health care through an Ohio Medicaid managed care plan (MCP).
Starting October 1, 2011, your managed care plan (MCP) will pay for prescription drugs and certain prescription medical supplies (diabetic supplies, inhaler spacers, peak flow meters, syringes, needles, alcohol wipes, and condoms). This means that you will need to get your prescription drugs at a pharmacy that accepts your MCP. You may no longer have to pay a co-payment for prescription drugs. Your MCP will notify you in writing if any co-payment for prescription drugs will apply to you.
This is how the changes will affect you when you get your prescription drugs and certain prescription medical supplies starting October 1, 2011.
- Starting October 1, you must use your new card to get prescriptions at the pharmacy, and to get medical supplies and other health care through your MCP. Your new card lets pharmacies know that your MCP will pay for your prescriptions. Contact your MCP if you do not receive your new card.
- You can get your prescription drugs at any pharmacy that accepts your MCP. Your MCP will only pay for prescriptions you get from pharmacies that have a contract with your MCP. Ask your pharmacy if it accepts your MCP. If you plan to travel out-of-state, be sure to fill your prescriptions before you leave.
- You can keep getting certain prescription medical supplies at no cost to you (diabetic supplies, inhaler spacers, peak flow meters, syringes, needles, alcohol wipes, and condoms). The pharmacy or medical equipment supplier cannot charge you for these prescription medical supplies. Contact your MCP about how to obtain your medical supplies.
- Your MCP will require your doctor to get prior authorization for some prescription drugs. Your MCP will not pay for some prescription drugs unless it gave your doctor prior authorization for the prescription. If your MCP requires prior authorization for one of your prescriptions but your doctor has not gotten it, the pharmacy will tell you that your MCP will not pay for the prescription unless your doctor gets prior authorization. If you need to fill the prescription immediately but your doctor is not available to get prior authorization, ask the pharmacy about giving you a short-term supply of the prescription.
Ask your doctor or pharmacy if there is another prescription that will work for you that does not require MCP prior authorization.
If Ohio Medicaid paid to refill a prescription on or after April 1, 2011 for a drug that needs MCP prior authorization and you need to refill the prescription on or after October 1, 2011:
- If it is for a controlled substance, you can refill it without MCP prior authorization until October 31, 2011. Controlled substances include many pain medications such as medications containing hyrdrocodone, some anxiety medications such as diazepam, and some seizure medications such as Phenobarbital. Ask your pharmacist whether any of your medications are controlled substances;
- If it is not for a controlled substance, you can refill it without MCP prior authorization until December 31, 2011;
- If it is for a tablet/capsule antidepressant or antipsychotic, or an injectible antipsychotic or an injectible antipsychotic, you can refill it without MCP prior authorization unless:
- It is not prescribed by a psychiatrist who has a contract with your MCP or whom you see at a Community Mental Health Center;
- Or is not prescribed for use as approved by the FDA.
- If either of these applies, then you can refill it without MCP prior authorization until January 31, 2012.
If you refill a prescription for a drug that needs MCP prior authorization, you will receive a letter from your MCP giving you information about what your doctor needs to do.
More information and help is available. Questions or problems with your prescription coverage or pharmacy? Questions or problems with your doctor? Contact your managed care plan (MCP) at the toll-free number on your member ID card.
Dec 28th, 2010 | by
To all those that help children with Medicaid coverage, we have a simple request – please make this New Year’s Resolution: I will help promote the importance of the Early Periodic Screening, Diagnosis & Treatment (EPSDT) program to those that I serve.
So it doesn’t sound that inspiring, but the benefits that we all realize when Medicaid children (all the way up to age 21) get their EPSDT exams are profound and long lasting.
For those unaware of what EPSDT is, here is the definition as stated by the US Department of Health and Human Services:
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is the child health component of Medicaid. It’s required in every state and is designed to improve the health of low-income children, by financing appropriate and necessary pediatric services.
Early- Identifying problems early, starting at birth
Periodic – Checking children’s health at periodic, age-appropriate intervals
Screening – Doing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
Diagnosis – Performing diagnostic tests to follow up when a risk is identified
Treatment – Treating the problems found.
In Ohio, the EPSDT program is called HealthChek. In Michigan, there is no official name for the state’s EPSDT program, but information can be found under Michigan’s MIChild and Healthy Kids Medicaid programs. Regardless of what it’s called, the program is the foundation for which the Medicaid program is built.
Why are we making this request? And why are we also dedicated to promoting EPSDT utilization? Because the exam helps millions of children stay healthy or find the care they need to get healthy. And the only way to make sure our most vulnerable children are cared for is to promote, promote, promote.
We want consumer advocacy groups that help underserved families and communities to talk with their families about the importance and availability of the EPSDT program, and to help them work with their Medicaid plan to find a doctor to administer the exam.
We want providers that take care of our underserved families and communities to proactively reach out to their Medicaid patients, and remind them that the EPSDT exam is so important – and free to the patient. Also, we encourage providers to make sure their billing staff is aware of the proper billing codes to ensure EPSDT services are reported and reimbursed correctly. In fact, in Ohio, each of the seven Medicaid health plans have partnered with the Ohio Department of Job and Family Services to hold a series of webinars with CEUs to educate providers about the importance of administering the full gamut of services covered by EPSDT as well as appropriate coding and billing procedures. Over 200 provider offices have participated in these webinars, and more will be scheduled in 2011.
We want our policy makers – as they are entrenching themselves in their district neighborhoods this holiday season – to remind their constituents about the importance of making sure our children are getting these important health care screenings early – BEFORE an illness becomes an emergency.
So the call to action is this…let’s all use our networks (social media networking and face-to-face networking) to increase awareness of the importance of an EPSDT exam, and promote, promote, promote. Point them to this article, as we are providing below all the necessary information to be educated on EPSDT exams, and their importance to making sure our underserved populations make preventive health care a priority.
And feel free to print and distribute the materials found at the following sites.
- In Ohio, the Medicaid care coordination plans have made it easier for doctors to make EPSDT claims through these standard forms
- Here is a brochure about EPSDT exams for Ohio
- Ohio Fact Sheet about HealthChek
- Here’s information for Michigan children on Medicaid
- CareSource has much information for providers about EPSDT exams, and how to file claims
- Recommendations for Preventive Pediatric Health Care as provided by the American Academy of Pediatrics
- Social Services directory for agencies within Ohio
- Ohio’s Medicaid Provider Directory & Search
Dec 20th, 2010 | by
Were you aware that as part of the health care reform law, small businesses (with 100 employees or less) will have an opportunity to get grant dollars from our government to implement workplace wellness programs? During fiscal years 2011 and 2012, there will be $200-million available for small business workplace wellness programs. Details regarding how to apply for these grants have not been released yet.
However, add this element of the Patient Protection & Affordable Care Act to those that cover preventive care procedures like mammograms and colonoscopies, and it’s obvious that our government is taking serious measures to promote preventive care and wellness in our new health care system.
Employer-sponsored wellness programs have been proven to be beneficial in a number of ways:
- Decreases in employee absenteeism and sick leave
- Increases in worker productivity
- Lower costs/less insurance claims
- Decrease in work related injuries
In fact, employers and employees are both in agreement that the employer has some responsibility in creating a positive, healthy atmosphere. According to research completed by STOP Obesity Alliance, 92 percent of employers at companies thought weight management programs were appropriate at work and eight out of 10 employees, no matter their weight, said weight management programs belong at work.
Many employers also bundle incentives into the wellness programs they initiate – like money, contributions to health savings accounts, gift certificates to spas or fitness facilities, etc. It just shows how important it is to employers for their employees to maintain healthy lifestyles – it benefits the business and it benefits the employee…a win/win.
Our Own Wellness Program
CareSource is not a small business – we have over 900 employees. However, since we are a Medicaid care coordination plan that promotes and develops programs around wellness for our members, we felt it was essential that we “walk the walk” by institutionalizing our own employer-sponsored wellness program. Wellness has always been a priority at CareSource, but we are enhancing and building our program to create a culture of health and wellbeing that is present and palpable in everything we do. We thought we would share what we are doing so far so that you might also take a look at creating or reviewing your own programs, and to see that implementing such a program really isn’t as hard as it might appear.
The first thing we did was lay the foundation that this is an employee led program. Our employee led team established our wellness mission and vision with the full support and encouragement of our executive team. So we know we have 100% agreement across the company.
To establish, encourage, and maintain a culture that promotes healthy lifestyles through education, environment, and policies to support employees’ efforts.
Create a community of health and well-being that improves health outcomes, reduces unnecessary health care costs and empowers individuals to take
an active role in their health.
Next, we are asking all of our employees to complete a health risk assessment. This will be confidential in nature, of-course, and will be used to understand health trends within our employees – not call out specific individuals regarding their health habits. There is an incentive all employees who fill out the assessment.
We are also forming an employee-led wellness committee within our organization. The committee will provide ongoing employee feedback, strategy recommendations and continuous improvement. The committee will then report to our executive advisory team. We will also have several employee led work groups to create activities and strategies in various areas within the wellness program, and report back to the committee. These work groups will be specifically responsible for:
- Program development, content and evolution
- Community engagement
- Communications methods and content
- WellZone (our in-house work out facility) and web site
- Wellness Wednesdays – designated day each month that will focus on a specific wellness initiative
- Incentive and engagement strategies
- Metrics and outcomes
We are calling this the Employees First© wellness program, and as we launch it, we will be looking to several initial indications of success before shifting our focus on longer term outcomes… Metrics we will be analyzing include:
- Completion of/participation in the health risk assessment
- HEDIS metric improvements
- Use of our online wellness tool (in development) that will be hosted on our intranet
- Use of the WellZone and participation in wellness activities across the sites
- Compliance with recommended preventive care guidelines
Do You Have a Wellness Program?
So our question to readers, does your business sponsor a wellness program? And if so, tell us a bit about it. We are always open to ideas and ways to build this program, and appreciate the advice from other businesses.
Nov 23rd, 2010 | by
A health care home – or medical home – model works best when all parties that touch the health care system are involved. That means having a collaborative effort among providers, patients and insurance. The overriding goal of a health care home model is to keep patients healthier while reducing the cost of care. This is a model that we support, certainly. But more importantly, it’s a model we are putting to practice in a number of ways.
Our recent alignment with the Ohio chapter of the American Academy of Pediatrics (AAP) is an ideal example of how collaboration can lead to better outcomes and improved quality. The CareSource Foundation recently awarded a signature grant of $75,000 to the Ohio chapter of the AAP supporting an asthma quality improvement initiative. As a result of the CareSource grant, CareSource will widen its focus on asthma quality improvement opportunities for physician practices throughout Ohio.
Currently, CareSource works with 13 practices in Ohio in a Medical Home pilot where physicians and CareSource as working together to identify patients whose asthma may not be well controlled. These practices include community health centers, hospital-based systems and private practices. Together, we have formed a medical collaborative to address issues of asthmatic children from birth through 18 years old among other conditions addressed.
Goals of the grant are to decrease hospitalizations, identify treatment options and form strategic asthma control plans to improve health outcomes for all children.
Collaboration Equals Results
Through our association with the Ohio Chapter of AAP, and the medical home pediatric offices, we are striving to educate and change behaviors in asthmatic patients. This is done through a combination of hands-on coordination and helping the patient and his/her family be more aware of the condition, and how to deal with it. A CareSource case manager is assigned to each practice, and is responsible for helping the patient carry out the instructions/recommendations that the doctors communicate.
Specifically, our pilot medical home teams are doing the following:
- Surveying patients and their families about asthma triggers
Doctors start by documenting with the patient and his/her parent or guardian the triggers that cause an asthma episode. By understanding what causes the episode, the hope is that the patient and family seek ways to avoid those incidences. Also, by knowing what the triggers are, families can make changes to their living environments to remove anything that causes an asthma episode. Episodic documentation is also part of the ongoing relationship between doctor and patient as unforeseen triggers can often arise.
- Consistent Care
Children with asthma do better by seeking regular care for their condition. So as a service to our members, we work hard with providers and patients to make sure patients are being seen regularly. We encourage doctors to keep a breathing peak-flow record of the patient so changes in the condition can be recognized and addressed. We also encourage doctors to assess and review changes in lung function on a regular basis to more effectively care for the child.
- Create an Action Plan
Working with the doctor and patient, we collaborate on an asthma action plan that strives to keep the patient healthy and avoid unnecessary doctor or emergency room visits. The action plan includes consistent doctor visits, prescription instructions, lifestyle/behavioral actions, ongoing monitoring, etc.
And We’re Seeing Results
Ohio currently ranks seventh in pediatric asthma incidences with nearly 10 percent of children suffering from asthma. For children living in poverty and of certain races, that number nearly doubles. So it’s easy to see why it’s important that we as a health care community strive to address asthma within the Medicaid population. Although our pilot program is in its infancy, we are already seeing positive results.
Of the children that see pediatricians in the pilot area practices, there has been a 30% drop in emergency room visits (when comparing 2008 to 2009). The overall awareness of asthma within the communities where the pilot program is taking place has also been raised. And lastly, since we are championing this alongside the Ohio Chapter of the American Academy of Pediatrics, we are removing many of the barriers of access to care.
As time goes on, we expect these results to be even stronger. We also anticipate adding provider practices to the pilot program as our results continue to deliver positively.
Some Fast Facts About Children with Asthma
- Ohio ranks seventh in pediatric asthma incidences with nearly 10 percent of children suffering from asthma
- Pediatric asthma accounts for 14.7 million days of school missed by children nationally each year and workdays missed by parents who stay home to take care of their children
- Acute asthma encounters can cost $400 per emergency department visit and $5,000 for inpatient care
Nov 16th, 2010 | by
Earlier this year, we launched an innovative, online tool for provider practices called the CareSource Clinical Practice Registry. We’ve seen adoption of the tool really take off mainly because the kind of information that the Clinical Practice Registry provides has traditionally been elusive when it comes to Medicaid patients.
A provider in our network – Dr. Barb Bennett, Family Practice Physician and past president of the Ohio Osteopathic Association – was kind enough to provide her points of view regarding the tool, and how it helps her organize her practice.
The primary benefit of the CareSource Clinical Practice Registry is population management. Providers can quickly and easily sort their CareSource membership into actionable groupings. It is a proactive approach to patient care and helps place emphasis on the need for preventive care.
For example, a Primary Care Provider (PCP) can sort the list to identify all of those with chronic conditions like diabetes. From the list of diabetics in the practice, the provider can identify those who need to come in for a visit, and proactively call to schedule an appointment. The report is color coded, so the provider can identify areas of focus. It can also be downloaded as a PDF or in an Excel spreadsheet format.
The Registry also impacts HEDIS scores. It helps identify many HEDIS mandated screenings, including women’s health and well-child screenings. By identifying the HEDIS screenings through the Registry, HEDIS quality scores improve, and most importantly, so do the health of our members.
Oct 13th, 2010 | by
As an Ohio Medicaid care coordination plan, we have been members of an association called the Disease Management Association of America. In fact, our medical director Dr. Gail Croall is a sitting member of the board. This has always been an important association to us because of their historical focus on care coordination for chronic diseases and health issues in all populations. And recently, the organization changed its name and brand image (but certainly not its mission) to the Care Continuum Alliance.
As the landscape of the health industry has evolved, so have the members of CCA. So we’re proud of CCA’s branding evolution as it aligns more closely with all players in the health care industry.
The focus on all parties within the health care industry is to not only promote healthy living and preventive health care, but to deliver on it.
So to Care Continuum Alliance, we applaud you on your name change and branding effort. We agree that this change better fits the landscape of health care in America. And we encourage our readers to learn more about Care Continuum Alliance – their dedication to promoting care coordination and preventive health care delivery continues to be an inspiration to all your members – like CareSource.
So a question to our readers in the industry, what steps have you taken to transform with the new health care landscape?