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In 2023, EmblemHealth is removing referral requirements for our Medicaid, HARP, Child Health Plus, and Essential Plan members.
Until the end of the COVID-19 State of Emergency, our Medicare Advantage Plans will continue to waive all referral requirements. Use these guides to see all plans with no referral requirements in 2023:
- 2023 EmblemHealth Plans That Do Not Need Referrals
- 2023 Summary of Companies, Lines of Business, Networks, and Benefit Plans
These referral changes apply to members managed by Health Care Partners, Montefiore, and SOMOS as well.
In case you missed it, make sure you review our Annual Provider Notification. It will help you prepare for 2023. To view updates for specific members, see:
We value our providers and your feedback and use what we hear to shape programs and services to improve your experience. One example is the development of our provider portal. We want to thank those of you who provided feedback and enabled us to deliver improvements, including:
- The new Check Provider Network Status tool and Care Plans on the portal.
- Expanded information for claim-line details, PCP Panel Reports, and PCP History.
- Improved navigation and standardization of information across screens.
You’ve also inspired us to create a new Provider Portal Advisory Group to give more people a say in how we continue developing our portal. We will send an invitation to our portal users to join.
Advisory group members will be invited to participate in brainstorming and priority setting sessions, surveys, and focus groups that are relevant to the work they do. We will be respectful of your time. In fact, our goal is to improve the provider portal so you can reduce the time spent on administrative tasks.
We welcome participation from all portal users to help us make it an even more useful and better experience.
January is Cervical Cancer Awareness Month. More than 13,000 women in the United States are diagnosed with invasive cervical cancer each year.
The good news is the disease is preventable with vaccination and appropriate screening. We encourage you to talk to your patients about getting Pap tests, HPV tests, and related vaccines.
The Centers for Disease Control and Prevention (CDC) recommends that all boys and girls get the HPV vaccine at age 11 or 12 since the vaccine produces a stronger immune response when taken during the preteen years. For this reason, up until age 14, only two doses of the vaccine are required. Complete the HPV vaccine series by age 13 to ensure gap closures for HEDIS. Proactive scheduling and call campaigns are often most effective for this measure.
Respiratory syncytial virus (RSV) causes annual epidemics of acute respiratory illnesses in children. These can range from mild upper respiratory tract infections to severe lower respiratory tract disease, including bronchiolitis or pneumonia. Severe RSV disease occurs primarily in infants younger than six months during their first fall and winter season of life. There are steps you can take to help your patients prevent the spread of RSV.
If any of your patients have cold-like symptoms, they should:
- Cover their coughs and sneezes with a tissue or upper shirt sleeve, not their hands.
- Wash their hands often with soap and water for at least 20 seconds.
- Avoid close contact with others, such as kissing, shaking hands, and sharing cups and eating utensils.
- Clean frequently touched surfaces such as doorknobs and mobile devices.
Ideally, people with cold-like symptoms should not interact with children at high risk for severe RSV disease, including premature infants, children younger than two years of age with chronic lung or heart conditions, and children with weakened immune systems. If this is not possible, they should carefully follow the prevention steps mentioned above and wash their hands before interacting with such children. They should also refrain from kissing high-risk children when having cold-like symptoms. Parents of children at high risk for developing severe RSV disease should help their child, when possible, do the following:
- Avoid close contact with sick people.
- Wash their hands often with soap and water for at least 20 seconds.
- Avoid touching their face with unwashed hands.
- Limit the time they spend in child-care centers or other potentially contagious settings, especially during fall, winter, and spring. This may help prevent infection and spread of the virus during the RSV season.
Educational content drawn from the following resources:
Important News from ConnectiCare
ConnectiCare has decided to no longer issue quotes to new customers for fully insured, small group health insurance plans as of Dec. 1, 2022, and not renew those plans to existing customers after May 31, 2023.
To help avoid gaps in coverage for affected members, our teams are working closely with the Connecticut Business and Industry Association (CBIA), Access Health CT, health insurance brokers, and the small group employers who must switch to new coverage arrangements on or before their next renewal.
As a ConnectiCare network provider, we wanted to let you know that only fully insured small group products are affected. ConnectiCare will continue to have a strong presence in Connecticut. We will continue to offer products to large employer groups, individuals, and small groups who are eligible for our ConnectiCare level-funded products.
MD Perspectives
Hello, colleagues.
This is the second part of a series on population health. This month we will look at:
- How we approach population health.
- The critical role of primary care; and
- How technology informs our programs for targeted populations.
“Population health” is a term most clinicians are aware of but may think of in different ways. At EmblemHealth and ConnectiCare, we are aligned with the CDC’s approach:
CDC views population health as an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes. Population health “brings significant health concerns into focus and addresses ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.”
Making population health changes requires a multi-pronged approach. Two of those prongs we are focusing on at EmblemHealth and ConnectiCare include primary care and the use of technology to predict who needs extra help.
Primary Care
Primary care plays a crucial role in a strong population health model. We have observed that patient-centered medical homes are an effective way of delivering proactive primary care. As medical directors, we want to see all of our members working with a primary clinician, regardless of whether or not there is an official primary care provider (PCP) designation through one of our benefit plan designs. Screenings, immunizations, and other preventive care can help our members achieve the healthy futures we envision for them. A strong primary care relationship, built over time and based on trust, can uncover other ways a patient needs help beyond the office visit and beyond the medical needs.
We understand the importance of removing barriers to primary care. That is why:
- Many of our plans have no or low member cost-sharing for primary care services.
- We offer financial incentives, such as:
- The Adult Comprehensive Health Assessment Provider Incentive Program to compensate providers who are not part of a value-based arrangement but help close gaps in care for our members with Medicare, Medicaid, and Essential plans.
- The EmblemHealth Medicare Member Rewards Program to encourage members to seek preventive care with their clinician.
Use of Technology
There are many ways technology can help improve population health. One way is the use of artificial intelligence (AI) in identifying targeted populations with special health needs. We can analyze data gathered from claims (hospital stays, pharmacy, and diagnosis) and utilization review requests from our own systems and those of our partners to identify patients with high comorbidities, predicting who can benefit from one of our Care/Case Management programs. We also use this data to inform when new programs are needed.
What’s Next?
Next month, we’ll look at how our approach to population health is influencing our perspectives on specific chronic conditions and how medical management within the plan helps our members and clinicians especially regarding social determinants of health.
Lama
Lama El Zein MD, MHA
Sr. Medical Director/Population Health and Clinician Engagement
If you missed Population Health - Part 1, see our November 2022 edition of Office Visit which covered:
- The unique perspective we, as medical directors for EmblemHealth and ConnectiCare, have on population health.
- How we are redesigning our own team.
- How we are improving transitions of care.
If there are other health topics you would like our perspectives on, please write to us at
emblemhealthmedicaldirectors@emblemhealth.com.
While we welcome your suggestions, we ask that you do not send protected health information (PHI) or patient-specific issues to this mailbox. This mailbox should not be used for complaints, grievances, appeals, or claims inquiries. The Claim Inquiry and Message Center features in the provider portals (EmblemHealth|ConnectiCare) should be used for those issues.
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