Connection supplemental articles and policies - November 2014

Supplemental articles

Payment policies

These policies apply to Fallon Health and Fallon Total Care unless otherwise noted.

New policies – effective January 1, 2015:

  • Newborns Services Payment Policy (Fallon Health only)
  • Skilled Nursing Facility Payment Policy

Revised policies – effective January 1, 2015:
The following policies have been updated; details about the changes are indicated on the policies. Go to

  • Radiology/Diagnostic Imaging Payment Policy – Updated to include prior authorization and billing information for low dose CT screening
  • Sleep Management Services Payment Policy – Updated prior authorization section
  • Transplant Payment Policy – Updated format

Pending policies
The revisions to the following policies have been delayed. When updates are available, the changes will be announced in the Connection and published on our website.

  • Durable Medical Equipment Payment Policy
  • Inpatient Medical and Payment Policy
  • Medical Supplies and Surgical Dressings Payment Policy

What’s new

Fallon Health looking to better manage DME services – Update

Fallon is reassessing our durable medical equipment services program as previously announced. Our goal is to make changes  to enhance the overall quality of services being delivered to Fallon members.

We anticipate that we’ll complete this reassessment during early 2015 and will update you in the coming months about the details and timing of this program. If you have any questions, please call Provider Relations at 1-866-275-3247, prompt 4.

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Fallon Health’s updated portfolio for 2015

Fallon has reevaluated its current product portfolio and made benefit adjustments to existing plan designs, introduced new plan designs and closed others. Our standardized Connector plans will have no changes for 2015.

The changes apply to our Direct Care, Select Care, Steward Community Care and Fallon Preferred Care (PPO) plans for all commercial small group and individual business products. They will be effective upon enrollment anniversary dates, starting January 1, 2015.

You’ll find benefit summaries for these merged-market products on our website.

Summary of changes

Changes to existing plan designs:

  • We’ve renamed our current Copay 1000 plan to be “Copay 1000 Low”.
  • We’ve changed the emergency room cost sharing to a $200 copayment for all Classic plans.

What’s new: We’ve introduced these plan designs:

  • Copay 1000 High
  • Deductible 1200
  • Deductible 3000 Classic

We’re closing the following plan designs (in all networks):

  • Coinsurance 10%
  • Coinsurance 20%
  • Deductible 1500
  • QHD 1500 HSA
  • Tiered Choice $0 Deductible (will remain available for large businesses only)
  • Tiered Choice $0/$2000 Deductible (will remain available for large businesses only)

All of our plan designs continue to include popular extras, like our It Fits! fitness reimbursement program (standard benefit is $400 family/$200 individual); My Healthy Health Plan, our wellness incentive program; a 20% discount on CVS/pharmacy brand health-related items; Oh Baby!; NurseConnect; and more.

If you have questions, please call Provider Relations at 1-866-275-3247, prompt 4.

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Let’s connect

It’s vaccine season

Protect at-risk patients with pneumococcal vaccine
Many of your patients ask for the flu vaccine at this time of year. During their visit, when appropriate, you might take the opportunity to also give them a pneumococcal vaccine. These vaccines can be given at the same time.

Pneumococcal disease is the cause of thousands of hospitalizations and deaths each year. Among those who contract the disease, those who are age 65 and older and adults with underlying medical conditions are at higher risk of death.

For your patients, getting vaccinated is the safest, most effective way to protect against this infection. You’ll find excellent information about pneumococcal disease and the vaccines at Please see our “Billing bytes” section in the print Connection for how to bill for the flu and pneumococcal vaccines.

Getting vaccines at pharmacies now easier for members
Effective September 1, 2014, Fallon Health adult members who have a prescription benefit through Fallon can get their flu or pneumococcal vaccines at most pharmacies in our network without first paying out of pocket. Both vaccines are covered in full—no cash up front, no reimbursement paperwork. Members will need to show their health plan ID card.

Of course, members may still get both vaccines at their doctor’s office. (Under Massachusetts law, individuals under age 18 must go to their primary care provider for these vaccinations.) See for more information.

Fallon is hosting a flu clinic at the Fallon Information Center in Shrewsbury, Mass., on Tuesday, November 11, 2014, from
12:00 p.m.-1:00 p.m. Individuals must register in advance by calling 1-888-807-2908 (press option 4). See

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New program helps members with COPD

Fallon Health has added chronic obstructive pulmonary disease (COPD) to its disease management program offerings.

Members with COPD have an opportunity to work with a health educator or nurse on symptom management and improving the quality of day-to-day life. The program gives special attention to medication/oxygen therapy, activity level/energy conservation and exercising to an appropriate level with their doctor’s consent.

Other programs available too
In addition to COPD, Fallon has several programs that support our members who have asthma, diabetes, and cardiac disease or heart failure. The programs are free and voluntary.

All members enrolled in a program receive disease-related biannual newsletters. Some members who are more at risk receive regular coaching over the telephone from a health educator or nurse. The calls focus on lifestyle behavioral changes and self-management tools. We want to give our members action steps for healthier living.

We welcome referrals for your patients, our Fallon members, to our disease management programs and look forward to working with you. For more information or to make a referral, please call our team at 1-800-333-2535, ext. 69898, Monday through Friday from 8:30 a.m. to 5:00 p.m. You also may use our online Disease Management/Health Promotions Referral Form at

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One-stop wellness at Fallon Information Center

The Fallon Information Center in the White City Shopping Center, Route 9 in Shrewsbury, is a great place for individuals to stop for a health screening, wellness class or just to learn more about health insurance. Walks-ins are always welcome!

This fall we continue to offer our Medicare Advantage sales presentations (Mondays at 10 a.m.) and Medicare Supplement presentations (Wednesdays at noon).

We’re also offering blood pressure screenings, yoga classes, a stress management program, our Quit to Win program, our 50 Days to Fabulous healthy lifestyles series and several special programs, including presentations in our Provider Speaker Series (on November 17 and December 12). Most programs are free and open to the public.

For the latest program information and hours, refer your patients to, or to the Information Center phone number, 1-866-209-5073.

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Quality focus

Reminder for obesity screening and counseling

Fallon Health recognizes that obesity is a common, serious and costly problem. Body mass index (BMI) screening is a useful tool to identify possible weight problems for adults. For children and teens, aged 2 through 19 years old, the BMI percentile charts should be used; for age 20 and over, use the Adult BMI Calculator.

BMI provides a reliable indicator of measures of body fat for most people and is used to screen for weight categories that may lead to health problems. The Centers for Disease Control and Prevention (CDC) offer an adult BMI calculator and a child and teen BMI calculator.

Pediatric preventive care recommendations ages 2 through 19 years
Screen at least annually for healthy weight. Assess growth parameters using height and weight, and plot the value on CDC’s growth, body mass index (BMI) and BMI percentile charts specifically for ages 2 through 19 years. Counsel the parents/guardian and children at least annually on the benefits of physical activity and eating a healthy diet to maintain a desirable weight for the child’s height.

Adults preventive care recommendations ages 20 to 65+ years
Screen at least annually for healthy weight by calculating the BMI, and counsel the individual on the benefits of physical activity and a healthy diet to maintain a desirable weight for his/her height.

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Fallon Radiation Safety Program reports overexposure risk

Fallon Health monitors and enhances patient safety as an organizational priority, and one way we continue to do so is our Radiation Safety Program. For example, using claims data, we identify members under the age of 50 who do not appear to have a cancer diagnosis but have received five or more helical computerized axial tomography (CT) scans (excluding those of the head).

In an effort to reduce the risk of overexposure, Fallon will continue to notify PCPs of record when their patients who are Fallon members meet or exceed this threshold. With the assistance of our provider community, our aim is to help individuals balance the cumulative risks of radiation exposure with the need for receiving necessary diagnostic image testing.

Fallon recognizes that it is not always the PCP who orders the imaging tests, but urges you to communicate this information to your patients to help them make informed decisions about future imaging exams.

Should you have any questions or if you’d like more information on this topic, please contact Robin Byrne, Fallon Quality Programs, at 1-508-368-9103.

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HEDIS update-2015

For a comprehensive list of HEDIS measures, including a description of what is measured and the care treatment or test that is required for compliance, please visit

Notable changes to HEDIS 2015 include:

New measures

  • Non-recommended PSA screening for Medicare
  • Three measures related to care of children who are taking antipsychotic medications—(1) Use of multiple concurrent antipsychotics in children and adolescents, age 1-17; (2) Metabolic monitoring for children and adolescents on antipsychotics; and (3) Use of first-line psychosocial care for children and adolescents on antipsychotics

Retired measures

  • Diabetes LDL screenings, LDL control, BP<140/80
  • Glaucoma screening
  • Cholesterol screening after cardiac events
  • Monitoring of people on persistent medications - anticonvulsants in all products

Revised existing measures

  • Osteoporosis management - Added an upper age limit of 85 and extended the look-back period to 24 months to align with guidelines; removed estrogens from osteoporosis therapies; and removed pathological fractures as fractures used to ID eligible population.
  • Controlling blood pressure - Revised definition of adequate control to include two different blood pressure thresholds based on age and diagnosis.

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Product spotlight

Introducing Community Care through the Health Connector

Fallon Health has been chosen by the Massachusetts Health Connector Board to be one of five ConnectorCare plans offered in Central Massachusetts in the coming year. We’ll be introducing Community Care during this year’s open enrollment period, which begins on November 15 for membership effective as early as January 1, 2015. Eligibility for ConnectorCare plans is income based.*

Community Care was built in partnership with Reliant Medical Group and Harrington HealthCare. It is a limited-network option for residents of Central Massachusetts who are looking for affordability, ease of use and trusted local providers. Our provider partners have embraced this concept, working with us to make sure that patients will receive the right care at the right time in the right place.

Our Community Care members will receive excellent coverage and pay lower monthly rates and very little out-of-pocket costs. The plan includes many of the benefits and extras our other Fallon members enjoy, such as It Fits! and The Healthy Health Plan, which offer financial incentives for being and becoming healthy.

Who is eligible?
Fallon is committed to supporting the Massachusetts Health Connector as it works to re-enroll the more than 400,000 Massachusetts individuals into new health plans for 2015—and in particular the approximately 40,000 of them who live in and around Worcester county.

We believe that Community Care will be a popular option with these local residents who are eligible to receive financial assistance from the state. These individuals include existing Commonwealth Care members whose coverage ends January 31, 2015, and those individuals who are currently enrolled in temporary Medicaid coverage but may no longer be eligible when they reapply.

The network
In addition to Reliant Medical Group and Harrington HealthCare, the Community Care network** is supplemented with selected additional providers: Saint Vincent Hospital; Harrington, HealthAlliance, Clinton and Marlborough community hospitals; UMass Memorial for tertiary care (with prior authorization only); and additional affiliated physicians—UMass Memorial and Health Alliance specialists.

For more information
Your patients who are interested may call us today to make an appointment with a Fallon Health enrollment assister at a location convenient for them. Call 1-508-368-9709.

Learn more by calling the Provider Relations Department at 1-866-275-3247, option 4.

* ConnectorCare plans have lower monthly premiums and lower out-of-pocket costs. Individuals or families living in Massachusetts with incomes at or below 300% of the federal poverty level (FPL) may qualify for ConnectorCare. Those with incomes above 300% FPL may still be eligible for subsidies to reduce the cost of insurance. They cannot be eligible for Medicare, MassHealth (Medicaid) or other public health insurance programs. Children under the age of 18 are not eligible for ConnectorCare plans, and would instead enroll in MassHealth.

** Community Care provides access to a network that is smaller than Select Care. In this plan, members have access to network benefits only from the providers in Community Care. Please consult the Find a Doctor tool at, or the Community Care provider directory—a paper copy can be requested by calling our Customer Service Department at 1-800-868-5200—to determine which providers are included in Community Care.

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FSP Medicare Advantage
New - An HMO with a point-of-service (POS) option

We are excited to offer for 2015 a new type of plan to people with Medicare in Hampden and Hampshire Counties. Fallon Senior Plan (FSP) Plus Enhanced Rx HMO-POS provides members with the ability to see certain types of providers, and access certain services, out-of-network. This plan will replace the current FSP Plus Enhanced Rx HMO.

Members wishing to stay with Fallon, and enroll in the FSP Plus Enhanced Rx HMO-POS or another Fallon option will have to complete a new enrollment form. They can also enroll online at, or telephonically by calling 1-888-377-1980.

An HMO-POS plan is a combination of a health maintenance organization (HMO) and a preferred provider organization (PPO). A POS functions like an HMO—the member must have an in-network PCP who manages and coordinates care—but like a PPO, the member can use out-of-network providers for certain services.

With FSP Plus Enhanced Rx HMO-POS, a member can receive care from a specialist—outside of the network—at the same in-network cost sharing. A PCP referral is needed. Other providers and services are also available out-of-network at varied cost sharing. If you have questions, please call Provider Relations at 1-866-275-3247, prompt 4.

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FSP Medicare Advantage
Fallon Senior Plan HMO update – 2015

At Fallon Health, we remain committed to our Fallon Senior Plan (FSP) Medicare Advantage product, which is available in all of Barnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk and Worcester counties, and parts of Franklin County.

During the Medicare Annual Election Period now through December 7, Fallon is offering a great selection of HMO plans with premiums ranging from $0 and up. Our HMO plans offer different cost-sharing for services such as inpatient hospital care, a doctor’s office visit or prescription drugs. We will continue to cover all Medicare-covered preventive services at zero cost-sharing.

2015 plan change
Fallon Senior Plan direct pay plans will be moving to a preferred/non-preferred pharmacy network. If members have their prescriptions filled at a preferred pharmacy, they will have lower cost sharing than if they have their prescription filled at a non-preferred pharmacy. Preferred pharmacies include CVS, Walgreens, Target, and approximately 48 other independent pharmacies across the state. For specific information see, or check the pharmacy directory under current members/plan documents at

► You’ll find detailed information about our Fallon Senior Plan HMO individual plans in our Summary of Benefits documents on

We also continue to offer a Medicare Supplement (Medigap) insurance option for individuals at very competitive premiums.

If your patients have questions
We’ll be happy to help your patients understand their options for 2015. Please refer them to our FSP Customer Service number, 1-800-325-5669, available seven days a week. Fallon is holding member meetings throughout our service area, where members can speak directly with an FSP representative. Members can find a list of scheduled meetings on Central Mass. FSP members also are encouraged to stop by the Fallon Information Center at the White City Shopping Center on Route 9 in Shrewsbury. See for hours.

If you have additional questions, please call Provider Relations at 1-866-275-3247, prompt 4.

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Insurance coverage updates

Coverage of dependent children to age 26
Under the Affordable Care Act (ACA), all commercial plans are required to offer coverage to dependent children until they reach their 26th birthday. While that requirement remains in effect, a provision of the Employer Shared Responsibility regulations (under ACA), which go into effect in 2015 and 2016, will require certain employers to offer coverage to dependent children reaching age 26—until the end of their birthday month.

What Fallon is doing—To facilitate compliance, Fallon will extend dependent coverage to the end of the month in which the dependent turns 26. We’ll make this change for all commercial plans beginning on January 1, 2015, as employers renew coverage.

Services for gender identity disorder
The Massachusetts Division of Insurance (DOI) has notified insurers that they must provide coverage for services related to gender identity disorder, including gender reassignment surgery, when medically necessary.

There has been no mandate enacted requiring insurers to cover these services, but the DOI cited several existing sources of legal authority at the state and federal level that prohibit discrimination against transgendered individuals. The DOI notice follows closely on the heels of a decision requiring Original Medicare to begin covering these services.

What Fallon is doing—Fallon is ready to treat medically necessary transgender surgery and related services as a covered benefit and we’ve implemented this change across our fully-insured commercial plans. Our Transgender Services – Clinical Coverage Criteria medical policy was effective August 1, 2014, and other related policies such as Cosmetic, Reconstructive and Restorative Services and Infertility Services already take a non-discriminatory position on transgender issues. In this issue of Connection, you’ll see that codes 55970 and 55980 related to sex transformation require plan prior authorization, effective January 1, 2015. Also, we’ve amended members’ Evidence of Coverage documents to reflect this coverage.

If you have additional questions, please call Provider Relations at 1-866-275-3247, prompt 4.

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Script alert

Responding to Caremark’s request for Medicare PA information

When you submit a prior authorization (PA) request for a pharmacy benefit medication (patient self-administered) for a Fallon Medicare member*, your office may receive a request for more information from our Pharmacy Benefit Manager, Caremark. It’s of the utmost importance that you respond to that request as soon as possible, preferably the same day.

The Centers for Medicare & Medicaid Services (CMS) strictly regulates the time allowed to review a pharmacy PA request and notify the member. Caremark must resolve requests within either 24 (urgent) or 72 (non-urgent) hours from the time of receipt. Not only does a clinical decision need to be made, but the member must be notified of the outcome within this time period. CMS regulations define this time period as including all days (which means weekends and holidays too).

If Caremark does not receive enough information, CMS requires that a decision be made based on the available information. If this results in a denial, any subsequent information that you send in within 60 days must be handled and reviewed as an appeal, per CMS regulations.

In the best interest of our members and your patients, please respond to Caremark requests for more information in a timely manner. Also, you can find on our website PA forms, which contain the information required.

* Our Medicare members include those in Fallon Senior Plan™, NaviCare®, Summit ElderCare® and Fallon Total Care®.

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