Notices and Announcments

Annual Medical Record Data Collection for Quality Reporting Begins Feb. 1, 2016
Blue Cross and Blue Shield of Texas (BCBSTX) collects performance data using specifications published by the National Committee for Quality Assurance (NCQA) for Healthcare Effectiveness Data and Information Set (HEDIS^®) and by the U.S. Department of Health and Human Services (HHS) for the Quality Rating System (QRS).

HEDIS is the most widely used and nationally accepted effectiveness of care measurement available and HHS requires reporting of QRS measures. These activities are considered health care operations under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule and patient authorization for release of information is not required.

To meet these requirements, BCBSTX will be collecting medical records using internal resources and leveraging independently contracted third party vendors, such as Enterprise Consulting Solutions, Inc. (ECS), HealthPort Technologies, LLC and IOD Incorporated. If you receive a request for medical records, we encourage you to reply within seven to 10 business days.

BCBSTX or one of the vendors referenced above may `be contacting your office or facility in January or February 2016 to identify a key contact person and to ascertain which data collection method your office or facility prefers (fax, secure email or onsite). Appointments for onsite visits will be scheduled with your staff, if applicable. You will then receive a letter outlining the information that is being requested, and the medical record request list with members’ names and the identified measures that will be reviewed.

If you have any questions about medical record requests, please contact BCBSTX at 972-766-6614.

HEDIS is a registered trademark of NCQA.

Enterprise Consulting Solutions, Inc. (ECS), HealthPort Technologies, LLC and IOD Incorporated are independent third party vendors that are solely responsible for the products or services they offer. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the services they offer, you should contact the vendor(s) directly.

Understanding the Federal Employee Program and OBRA Part A
The Federal Employee Program (FEP) is unique in many ways. The federal government writes the policy that is administered and federal laws apply to the program contracts. While many of these federal laws are not written specifically in the provider contract, they must be complied with.

One such law is the Omnibus Reconciliation Act of 1990 (OBRA ’90), which initially included only the Part A component of OBRA. The act was amended in 1993, adding OBRA ’93 Part B. OBRA affects patients who are 65 or over who do not have Medicare coverage and are on the plan as a policyholder, annuitant, former spouse or as a covered family member of an annuitant or former spouse. In addition, it limits plan benefits to those to that the patient would have been entitled if they had Medicare coverage. The provider’s contracting status with Medicare and with the plan determines the maximum amount for which the patient can be billed.

How Part A and Part B Work
OBRA ’90 Part A only applies to inpatient services. The OBRA ’90 pricing allowance is calculated based upon Medicare DRG pricing. If the patient has no Medicare and is not employed by an entity that confers with an FEP benefit plan, plan benefits will apply, and the claim will be paid according to the Medicare allowance for the stay. If the patient has Part B coverage, claims for the ancillary services will still need to be submitted to Medicare for payment. The Explanation of Medicare Benefits (EOMB) will also need to be included with the claim. The plan will consider the payment that Medicare made on the claim.

For OBRA ’93 Part B, the allowed amount will apply if there is an equivalent Medicare allowable for your service. If there is no Medicare equivalent, the plan allowance will apply. Some Services, such as laboratory, ambulance, and durable medical equipment, are not subject to OBRA ’93 pricing. Please keep in mind that if a patient is over 65 and actively working, OBRA ’90 and OBRA ’93 do not apply. You may consult the plan for a further explanation of how both the Part A and Part B claims are processed.

2015 to 2016 Medicare Part D Formulary Changes
Blue Cross MedicareRx (PDP)^SM/Blue Cross Medicare Advantage (HMO)^SM/ Blue Cross Medicare Advantage (HMO-POS)^SM /Blue Cross Medicare Advantage (PPO)^SM
Based on Centers for Medicare & Medicaid Services (CMS) mandates (e.g., safety concerns, drugs that no longer meet the CMS definition of a “Part D medication,” etc.) and a regular review of changes in the pharmaceutical marketplace, the Blue Cross MedicareRx/Blue Cross Medicare Advantage 2016 Part D plans will have formulary and utilization management changes for 2016.

Members/subscribers  were alerted of these changes in late November 2015 via targeted mailings, as well as in the Annual Notice of Change (ANOC) sent to all current members with Blue Cross MedicareRx/Blue Cross Medicare Advantage Medicare Part D plans.

Visit the Pharmacy Program/Medicare Part D Updates sections of the BCBSTX provider website for a quick reference that includes the “Top 30” medications impacted by these formulary changes. Visit the BCBSTX Medicare website for the full 2016 formulary.

Members/subscribers are instructed to ask their doctors about the medications they are prescribed, if any of these formulary, quantity limit or prior authorization changes may impact them and  to have a prescription written for a formulary alternative. If the alternative is not appropriate for your patient, please start a coverage determination for the medication needed. Forms are available on our Medicare website under “Drug Information > Utilization Management”.

Blue Cross Medicare Advantage PPO plans are provided by HCSC Insurance Services Company (HISC), and HMO plans provided by GHS Insurance Company (GHS), Independent Licensees of the Blue Cross and Blue Shield Association. HISC and GHS are Medicare Advantage organizations with a Medicare contract. Enrollment in HISC’s and GHS’ plans depends on contract renewal.

Blue Cross MedicareRx is a prescription drug plan provided by HCSC Insurance Services Company HISC, an Independent Licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plan depends on contract renewal.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s/subscriber's  certificate of coverage, which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members/subscribers should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member/subscriber and their health care provider.

Provider Medicare Enrollment Information
You may have received a message from The Centers for Medicare and Medicaid Services (CMS) if you currently prescribe drugs to Medicare patients, but you are not enrolled in (or validly opted-out of) Medicare. This is a new requirement that CMS will begin enforcing on June 1, 2016.

The new rule requires that all providers who prescribe drugs for Part D patients must enroll in Medicare (or validly opt out, if appropriate). This is important to providers because unless you enroll (or validly opt out), Medicare Part D plans will be required to notify your Medicare patients that you are not able to prescribe covered Part D drugs.

Please also note that if you opt out of Medicare, you cannot receive reimbursement from traditional Medicare or a Medicare Advantage plan, either directly or indirectly (except for emergency and urgent care services; see 42 CFR 405.440 for details.) Please refer to the attached CMS letter for more information on this requirement for enrollment (or valid opt out). CMS contact information is also included in the letter if you have questions regarding this regulation.