Provider Education Webinar For over 45 years,
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Provider Education Webinar For over 45 years, VillageCare has delivered health care services to individuals residing within New York City guided by the core value of respect for those in its care and responsiveness to individual needs.
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01
Provider Education Webinar<br>
02
For over 45 years, VillageCare has delivered health care services to individuals residing within New York City – guided by the core value of respect for those in its care and responsiveness to individual needs.
VillageCareMAX’s coverage area includes Brooklyn, Manhattan, Queens,Bronx, Staten Island, Nassau and Westchester counties. In 2025, we will be expanding to Putnam county.*
*(pending SDOH approval) 2<br>
VillageCareMAX’s coverage area includes Brooklyn, Manhattan, Queens,Bronx, Staten Island, Nassau and Westchester counties. In 2025, we will be expanding to Putnam county.*
*(pending SDOH approval) 2<br>
03
3 We Bring a Personal Approach When it comes to our members, we take a personal approach to their care. The result is a comprehensive, team-based care plan that anticipates and adapts to the changing needs of each member, striving to keep them secure, independent and living in the comfort of their own home.
As a provider, you spend your time providing the best health care to your patients. LET US TAKE CARE OF THE REST.<br>
As a provider, you spend your time providing the best health care to your patients. LET US TAKE CARE OF THE REST.<br>
04
Partnership for Better Health and Well-Being 4<br>
05
5 VillageCareMAX Plan Advantages ONE CARD for both VillageCareMAX Medicare and Medicaid services.
ONE NUMBER to reach all MLTC member services: 1-800-469-6292 (TTY 711), 7 days a week, 8:00 am to 8:00 pm, and ONE NUMBER to reach all Medicare member services: 1-855-296-8800.
ONE PLAN to make it easier to get the services needed, when they are needed.<br>
ONE NUMBER to reach all MLTC member services: 1-800-469-6292 (TTY 711), 7 days a week, 8:00 am to 8:00 pm, and ONE NUMBER to reach all Medicare member services: 1-855-296-8800.
ONE PLAN to make it easier to get the services needed, when they are needed.<br>
06
Leads from Hospitals, Doctor’s Offices, Community Based Organizations Brochures or Referral Forms can be left behind at facility and if patient/prospect is interested in learning about our MAP, the BRC or Referral form can be signed by patient for a VillageCareMAX representative to conduct an outreach.
Signed BRC or Referral Form can be scanned and emailed to Medicare Sales Manager to screen for proper eligibility and assign to a Benefit Advisor.
Email form to: SalesOps@villagecare.org
If a Social Worker has a potential member interested in learning about our MAP plan, Social Worker can call with patient or legal representative to Member Services Department at 1-855-296-8800. 6<br>
Signed BRC or Referral Form can be scanned and emailed to Medicare Sales Manager to screen for proper eligibility and assign to a Benefit Advisor.
Email form to: SalesOps@villagecare.org
If a Social Worker has a potential member interested in learning about our MAP plan, Social Worker can call with patient or legal representative to Member Services Department at 1-855-296-8800. 6<br>
07
Claims 7<br>
08
VillageCareMAX Claims Processing and Billing There are important changes to how you submit medical claims from January 1st, 2025
On the following slides, changes are marked with
There is no change to how you submit behavioral health, vision, dental, or pharmacy claims 8 NEW<br>
On the following slides, changes are marked with
There is no change to how you submit behavioral health, vision, dental, or pharmacy claims 8 NEW<br>
09
VillageCareMAX Claims Processing and Billing Starting January 1st, 2025
Submit all physical health claims through the Availity clearinghouse (https://apps.availity.com)
Submit through Availity for all dates of services (inc. 2024 dates of service if the claim is submitted in 2025)
Use VillageCareMAX Payer ID: 26545
Electronic Claims must be submitted in 837I or 837P format. 9 Electronic Claims Submission NEW NEW<br>
Submit all physical health claims through the Availity clearinghouse (https://apps.availity.com)
Submit through Availity for all dates of services (inc. 2024 dates of service if the claim is submitted in 2025)
Use VillageCareMAX Payer ID: 26545
Electronic Claims must be submitted in 837I or 837P format. 9 Electronic Claims Submission NEW NEW<br>
10
VillageCareMAX Claims Processing and Billing For Dates of Service from Jan 1st, 2025 onwards
• Mail original and corrected claims to:
VillageCareMAX Claims
PO Box 3238
Scranton, PA 18505
For Dates of Service through Dec 31st, 2024
• Continue to mail original claims to:
ILS – VillageCare, PO Box 21516, Eagan, MN 55121
• Continue to mail corrected claims to:
ILS – VillageCareMAX, Provider Services Department, P. O. Box 21516, Eagan, MN 55121 10 Paper Claims Submission NEW<br>
• Mail original and corrected claims to:
VillageCareMAX Claims
PO Box 3238
Scranton, PA 18505
For Dates of Service through Dec 31st, 2024
• Continue to mail original claims to:
ILS – VillageCare, PO Box 21516, Eagan, MN 55121
• Continue to mail corrected claims to:
ILS – VillageCareMAX, Provider Services Department, P. O. Box 21516, Eagan, MN 55121 10 Paper Claims Submission NEW<br>
11
VillageCareMAX Claims Processing and Billing Hospital Inpatient/ER claims: Submit a single claim for the date range starting in 2024 and ending in 2025.
All other claims: Submit two separate claims – one for the 2024 dates of service and one for the 2025 dates of service.
If you received a single authorization for the date range, attach the same authorization number to both claims
If you received separate authorization numbers for 2024 vs 2025, make sure to attach the correct authorization number to each claim. 11 Claims for Date Ranges Spanning 2024 and 2025 NEW<br>
All other claims: Submit two separate claims – one for the 2024 dates of service and one for the 2025 dates of service.
If you received a single authorization for the date range, attach the same authorization number to both claims
If you received separate authorization numbers for 2024 vs 2025, make sure to attach the correct authorization number to each claim. 11 Claims for Date Ranges Spanning 2024 and 2025 NEW<br>
12
VillageCareMAX Claims Processing and Billing Timely Filing: Claims for authorized services must be submitted to VillageCareMAX generally within ninety (90) days from the date of service, but providers should always review their contracts for specific timely filing timeframes.
Electronic Funds Transfer (EFT) Enrollment & Changes: Complete the EFT form on our website and submit to ProviderRelations@villagecare.org
Electronic Remittance Advice (ERA):
Starting January 1st, 2025, enroll for ERA through the Availity portal https://apps.availity.com
Through December 31st, 2024, continue to use Ability/Inovalon for ERAs 12 Other Claims Submission Information NEW NEW<br>
Electronic Funds Transfer (EFT) Enrollment & Changes: Complete the EFT form on our website and submit to ProviderRelations@villagecare.org
Electronic Remittance Advice (ERA):
Starting January 1st, 2025, enroll for ERA through the Availity portal https://apps.availity.com
Through December 31st, 2024, continue to use Ability/Inovalon for ERAs 12 Other Claims Submission Information NEW NEW<br>
13
VillageCareMAX Claims Inquiries, Disputes, and Appeals For dates of service from January 1st, 2025:
To review claims status and determination: Use the Availity portal https://apps.availity.com
For inquiries, call Provider Services on 1-855-769-2500 and when prompted, select the option for dates of service from 2025
For dates of service through December 31st, 2024
To review claims status and determination, use the VillageCareMAX Provider Portal: https://secure.healthx.com/villagecareprovider
For inquiries:
Submit using the VillageCareMAX Provider Portal (https://secure.healthx.com/villagecareprovider), or;
Call Provider Services on 1-855-769-2500 and when prompted, select the option for dates of service through 2024 13 Claims Status & Inquiries NEW<br>
To review claims status and determination: Use the Availity portal https://apps.availity.com
For inquiries, call Provider Services on 1-855-769-2500 and when prompted, select the option for dates of service from 2025
For dates of service through December 31st, 2024
To review claims status and determination, use the VillageCareMAX Provider Portal: https://secure.healthx.com/villagecareprovider
For inquiries:
Submit using the VillageCareMAX Provider Portal (https://secure.healthx.com/villagecareprovider), or;
Call Provider Services on 1-855-769-2500 and when prompted, select the option for dates of service through 2024 13 Claims Status & Inquiries NEW<br>
14
VillageCareMAX Claims Inquiries, Disputes, and Appeals For dates of service from January 1st, 2025:
Mail to:
VillageCareMAX Claims PO Box 3238 Scranton PA 18505
Fax to (855) 864-7385
For dates of service through December 31st, 2024
Submit using the VillageCareMAX Provider Portal (https://secure.healthx.com/villagecareprovider), or;
Mail to:
ILS – VillageCareMAX Provider Services Department P.O. Box 21516 Eagan, MN 55121 14 Claims Disputes and Appeals NEW<br>
Mail to:
VillageCareMAX Claims PO Box 3238 Scranton PA 18505
Fax to (855) 864-7385
For dates of service through December 31st, 2024
Submit using the VillageCareMAX Provider Portal (https://secure.healthx.com/villagecareprovider), or;
Mail to:
ILS – VillageCareMAX Provider Services Department P.O. Box 21516 Eagan, MN 55121 14 Claims Disputes and Appeals NEW<br>
15
Member Eligibility and Authorization 15<br>
16
VillageCareMAX Member Eligibility For dates of service from January 1st, 2025:
Use the Availity Portal: https://apps.availity.com
Free to create an account
For dates of service through December 31st, 2024
Use the VillageCareMAX Provider Portal https://secure.healthx.com/villagecareprovider 16 Confirming Member Eligibility NEW<br>
Use the Availity Portal: https://apps.availity.com
Free to create an account
For dates of service through December 31st, 2024
Use the VillageCareMAX Provider Portal https://secure.healthx.com/villagecareprovider 16 Confirming Member Eligibility NEW<br>
17
Provider Authorization Portal Guiding Care- Altruista The Provider Authorization Portal is a tool for providers to electronically submit authorizations and receive automated responses and real-time updates.
Providers can request authorization for services, follow up on the status, and add supporting documentation. 17<br>
Providers can request authorization for services, follow up on the status, and add supporting documentation. 17<br>
18
PROVIDER PORTAL: vcm.guidingcare.com/AuthorizationPortal/
Authorizations Tel: 800-469-6292; 7 days/week 8 am - 8 pm
All Fax Numbers should be used for requests related to authorizations including authorization changes, authorization corrections, authorization modifications, clinical & supporting documentation, and prior authorization forms.
Inpatient Admissions Fax: 212-402-4468 Inpatient admissions; UR requests, Clinical, Discharge Summaries.
Outpatient Services Fax: 978-367-1872 (CHHA, In-Home & Outpatient OT, PT, ST, Nursing Services, Home Infusions) including New & Continuing Service Requests.
LHCSA/CDPAS/Personal Care Fax: 646-618-8997 PCA and CDPAS including Overtime Requests.
Long Term Support Services Fax: 646-362-2004 SADC, ADHC, PERS, Home-Delivered Meals, and Home Modifications.
DME Fax: 718-517-2709 Requests for all new & existing DME/ Medical Necessity, Prescriptions.
Grievance and Appeals Fax: 347-226-5180 All requests related to grievance and appeals.
Part B Fax: 917-243-9997 All requests related to authorizations for Part B Drugs, including New & Continuing Service Requests.
Skilled Nursing Facility Admissions Fax: 978-967-8030 All information regarding Skilled Nursing Facility Admissions, including: PRI and Short-Term Rehab Requests, Clinicals, Discharge Summaries, Requests for Continuity of Care, etc. 18<br>
Authorizations Tel: 800-469-6292; 7 days/week 8 am - 8 pm
All Fax Numbers should be used for requests related to authorizations including authorization changes, authorization corrections, authorization modifications, clinical & supporting documentation, and prior authorization forms.
Inpatient Admissions Fax: 212-402-4468 Inpatient admissions; UR requests, Clinical, Discharge Summaries.
Outpatient Services Fax: 978-367-1872 (CHHA, In-Home & Outpatient OT, PT, ST, Nursing Services, Home Infusions) including New & Continuing Service Requests.
LHCSA/CDPAS/Personal Care Fax: 646-618-8997 PCA and CDPAS including Overtime Requests.
Long Term Support Services Fax: 646-362-2004 SADC, ADHC, PERS, Home-Delivered Meals, and Home Modifications.
DME Fax: 718-517-2709 Requests for all new & existing DME/ Medical Necessity, Prescriptions.
Grievance and Appeals Fax: 347-226-5180 All requests related to grievance and appeals.
Part B Fax: 917-243-9997 All requests related to authorizations for Part B Drugs, including New & Continuing Service Requests.
Skilled Nursing Facility Admissions Fax: 978-967-8030 All information regarding Skilled Nursing Facility Admissions, including: PRI and Short-Term Rehab Requests, Clinicals, Discharge Summaries, Requests for Continuity of Care, etc. 18<br>
19
19 VillageCareMAX Plan Advantages ONE CARD for both VillageCareMAX Medicare and Medicaid services.
ONE NUMBER to reach all member services: 1-800-469-6292 (TTY 711), 7 days a week, 8:00 am to 8:00 pm.
ONE PLAN to make it easier to get the services needed, when they are needed.<br>
ONE NUMBER to reach all member services: 1-800-469-6292 (TTY 711), 7 days a week, 8:00 am to 8:00 pm.
ONE PLAN to make it easier to get the services needed, when they are needed.<br>
20
Leads from Hospitals, Doctor’s Offices, Community Based Organizations (Now using V12 link) Brochures or Referral Forms can be left behind at facility and if patient/prospect is interested in learning about our MAP, the BRC or Referral form can be signed by patient for a VillageCareMAX representative to conduct an outreach.
Signed BRC or Referral Form can be scanned and emailed to Medicare Sales Manager to screen for proper eligibility and assign to a Benefit Advisor.
Email form to: SalesOps@villagecare.org
If a Social Worker has a potential member interested in learning about our MAP plan, Social Worker can call with patient or legal representative to Member Services Department at 1-800-469-6292. 20<br>
Signed BRC or Referral Form can be scanned and emailed to Medicare Sales Manager to screen for proper eligibility and assign to a Benefit Advisor.
Email form to: SalesOps@villagecare.org
If a Social Worker has a potential member interested in learning about our MAP plan, Social Worker can call with patient or legal representative to Member Services Department at 1-800-469-6292. 20<br>
21
Provider Relations Account Manager Contact Information 21 Orlando Santos Sergio Ferguson Yarha Frederique David Godoy Darlene
Bullock Jackson<br>
Bullock Jackson<br>
22
Plan Product Array/Benefit Plan Updates Effective January 1, 2025 22<br>
23
23 VillageCareMAX - 2025 Plan Products Managed Long-Term Care (MLTC):
VillageCareMAX MLTC is a Medicaid Managed Care Long-Term Care (MLTC) plan that provides members with long-term care services and supports like personal care, adult day health care and others. This product is for Medicaid eligible individuals.
Medicaid Advantage Plus (MAP):
VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs as well as long-term care services and supports who are dual eligible for Medicare and Medicaid.
Dual Special Needs Plan (HMO DSNP):
VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs who are dually eligible for Medicare and Medicaid. Individuals must live in the counties in which VillageCareMAX is licensed to operate.
FLEX Dual Special Needs Plan (HMO DSNP):
VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs who are dually eligible for Medicare and Medicaid. Individuals must live in the counties in which VillageCareMAX is licensed to operate. With the FLEX benefit option, members can get even more covered services to fit their dental, vision or hearing needs.
Medicare Select Advantage Plan (HMO):
VillageCareMAX Non-D-SNP Medicare Plan is intended for members who are Medicare eligible and get financial full “Extra Help“, also referred to as the Low-Income Subsidy plan (LIS). This plan offers members supplemental benefits such as vision, hearing, and dental.<br>
VillageCareMAX MLTC is a Medicaid Managed Care Long-Term Care (MLTC) plan that provides members with long-term care services and supports like personal care, adult day health care and others. This product is for Medicaid eligible individuals.
Medicaid Advantage Plus (MAP):
VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs as well as long-term care services and supports who are dual eligible for Medicare and Medicaid.
Dual Special Needs Plan (HMO DSNP):
VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs who are dually eligible for Medicare and Medicaid. Individuals must live in the counties in which VillageCareMAX is licensed to operate.
FLEX Dual Special Needs Plan (HMO DSNP):
VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs who are dually eligible for Medicare and Medicaid. Individuals must live in the counties in which VillageCareMAX is licensed to operate. With the FLEX benefit option, members can get even more covered services to fit their dental, vision or hearing needs.
Medicare Select Advantage Plan (HMO):
VillageCareMAX Non-D-SNP Medicare Plan is intended for members who are Medicare eligible and get financial full “Extra Help“, also referred to as the Low-Income Subsidy plan (LIS). This plan offers members supplemental benefits such as vision, hearing, and dental.<br>
24
24 2025 Medicare Portfolio<br>
25
25 Special Supplemental Benefits for the Chronically Ill (SSBCI)
and Value-Based Insurance Design (VBID) In 2025, VillageCareMAX is converting its SSBCI offering to VBID for MHA and MHA Flex plans with SSBCI continuing to be offered for MAP plan Members qualify for SSBCI due to being chronically ill enrollees based on the CMS definition. VillageCareMAX qualifies members for VBID based on socioeconomic status (receiving Low Income Subsidy)
As a function of the plans’ designs, VillageCareMAX MAP members qualify for SSBCI and MHA/MHA Flex plan members qualify for VBID.<br>
and Value-Based Insurance Design (VBID) In 2025, VillageCareMAX is converting its SSBCI offering to VBID for MHA and MHA Flex plans with SSBCI continuing to be offered for MAP plan Members qualify for SSBCI due to being chronically ill enrollees based on the CMS definition. VillageCareMAX qualifies members for VBID based on socioeconomic status (receiving Low Income Subsidy)
As a function of the plans’ designs, VillageCareMAX MAP members qualify for SSBCI and MHA/MHA Flex plan members qualify for VBID.<br>
26
26 2025 Supplemental Benefit Highlights – MAP and D-SNP<br>
27
27 2025 Supplemental Benefit Highlights – D-SNP Flex and MSA<br>
28
28 2025 Pharmacy Changes at-a-glance<br>
29
Carelon Behavioral
Health EFFECTIVE JANUARY 1, 2024 11<br>
Health EFFECTIVE JANUARY 1, 2024 11<br>
30
Carelon is a national leader in the fields of mental and emotional wellbeing, addiction treatment and recovery. Carelon serves over 13 million Medicaid members in 19 states.
Carelon administers behavioral health benefit coverage for more than 4 million Medicaid managed care members statewide, representing about a quarter of all New Yorkers with health care coverage. Carelon Overview 12<br>
Carelon administers behavioral health benefit coverage for more than 4 million Medicaid managed care members statewide, representing about a quarter of all New Yorkers with health care coverage. Carelon Overview 12<br>
31
Behavioral Health Services provided through
Carelon Emergency BH Services
Psychiatric or Substance Use Disorder (SUD) unit/service
Comprehensive Psychiatric Emergency Program (CPEP) services
Inpatient Admissions for BH services Inpatient Psychiatric Admission
SUD, Withdrawal Management, Detox
Psychiatric/SUD assessments, evaluations, & consults
Outpatient Treatment for BH Services Psychological or Neuropsychological Testing
Primary Treatment for SUD with BH provider
Services rendered in OMH/OASAS Setting
Other Adult BH Services
Partial Hospitalization; Assertive Community Treatment (ACT); Continuing Day Treatment; Personalized Recovery Oriented Services (PROS); Crisis Intervention Services (incl. mobile crisis); CORE Services<br>
Carelon Emergency BH Services
Psychiatric or Substance Use Disorder (SUD) unit/service
Comprehensive Psychiatric Emergency Program (CPEP) services
Inpatient Admissions for BH services Inpatient Psychiatric Admission
SUD, Withdrawal Management, Detox
Psychiatric/SUD assessments, evaluations, & consults
Outpatient Treatment for BH Services Psychological or Neuropsychological Testing
Primary Treatment for SUD with BH provider
Services rendered in OMH/OASAS Setting
Other Adult BH Services
Partial Hospitalization; Assertive Community Treatment (ACT); Continuing Day Treatment; Personalized Recovery Oriented Services (PROS); Crisis Intervention Services (incl. mobile crisis); CORE Services<br>
32
Collaborative Care Continued Screening of Members Screening for Depression, Anxiety, Substance Use Disorders and tobacco use by PCP.
Screening of high-risk medical population for BH conditions and/or psychosocial stressors that may impact their medical condition or adherence to treatment regimens. Referral for Behavioral Health Services Referrals to be made directly to Carelon Behavioral Health for behavioral health services. Treatment and Collaboration with Behavioral Health Providers SBRIT- Screening, Brief Intervention, Referral and Treatment.
Use of BH Clinical Guidelines for BH conditions commonly treated in primary care settings.<br>
Screening of high-risk medical population for BH conditions and/or psychosocial stressors that may impact their medical condition or adherence to treatment regimens. Referral for Behavioral Health Services Referrals to be made directly to Carelon Behavioral Health for behavioral health services. Treatment and Collaboration with Behavioral Health Providers SBRIT- Screening, Brief Intervention, Referral and Treatment.
Use of BH Clinical Guidelines for BH conditions commonly treated in primary care settings.<br>
33
Screen
To determine level of Alcohol, Drug Use, and any related problems Low or no Alcohol or Drug Use Provide positive feedback of
benefits Moderate Alcohol or Drug Use, Signs of related risks Brief Intervention Significant Alcohol or Drug Use, signs of multiple risks Referral to Treatment SBRIT Model (Screening, Brief Intervention, Referral and Treatment)<br>
To determine level of Alcohol, Drug Use, and any related problems Low or no Alcohol or Drug Use Provide positive feedback of
benefits Moderate Alcohol or Drug Use, Signs of related risks Brief Intervention Significant Alcohol or Drug Use, signs of multiple risks Referral to Treatment SBRIT Model (Screening, Brief Intervention, Referral and Treatment)<br>
34
Carelon Provider Contact Information for Participation Status Provider Participation Status
To continue to provide behavioral health services to VillageCareMAX MAP and DSNP members, you must be a participating behavioral health provider with VillageCareMAX through the Carelon network. Carelon Provider Contact Information
To check your Carelon participation status, or to join the VillageCareMAX provider network through Carelon, please contact Carelon at:
https://www.carelonbehavioralhealth.com/providers/join-our-network
Carelon’s National Provider Services line (all provider inquiries):
(800) 397-1630, Monday to Friday, 8 a.m. - 8 pm EST, Monday through Friday.<br>
To continue to provide behavioral health services to VillageCareMAX MAP and DSNP members, you must be a participating behavioral health provider with VillageCareMAX through the Carelon network. Carelon Provider Contact Information
To check your Carelon participation status, or to join the VillageCareMAX provider network through Carelon, please contact Carelon at:
https://www.carelonbehavioralhealth.com/providers/join-our-network
Carelon’s National Provider Services line (all provider inquiries):
(800) 397-1630, Monday to Friday, 8 a.m. - 8 pm EST, Monday through Friday.<br>
35
Customer Experience 24<br>
36
25<br>
37
26<br>
38
27<br>
39
28 Our Community Centers Manhattan Walk-In Center
112 Charles Street
New York, New York 10014
Tel: 800-469-6292
Brooklyn Community Center
6120 7th Avenue
Brooklyn, New York 11220
Tel: 800-469-6292 Flushing Community Center
41-80 Main Street
Flushing, New York 11355
Tel: 800-469-6292
Bronx Community Center
798 Southern Blvd.
Bronx, New York, 10455
Tel: 800-469-6292<br>
112 Charles Street
New York, New York 10014
Tel: 800-469-6292
Brooklyn Community Center
6120 7th Avenue
Brooklyn, New York 11220
Tel: 800-469-6292 Flushing Community Center
41-80 Main Street
Flushing, New York 11355
Tel: 800-469-6292
Bronx Community Center
798 Southern Blvd.
Bronx, New York, 10455
Tel: 800-469-6292<br>
40
Care Management 29<br>
41
Care Management Care Management is a collaborative process that helps coordinate and manage the care needs of members with complex and chronic conditions.
Core Components:
Assessment and identification of member needs
Medication management
Developing individualized care plans
Coordinating across healthcare providers and services
Managing Transitions of care
Educating members on health management and self-care
Resource Navigation 41<br>
Core Components:
Assessment and identification of member needs
Medication management
Developing individualized care plans
Coordinating across healthcare providers and services
Managing Transitions of care
Educating members on health management and self-care
Resource Navigation 41<br>
42
Care Management Team Construct 42<br>
43
Care Management Improving health outcomes through coordinated and personalized care Assessment & Care Planning Transitional Care Enhanced Care Coordination Behavioral Health & Social Support Services Health Promotion & Disease Management Care Manager
Outreach Assist members in managing chronic conditions like diabetes, heart disease, and COPD.
Provide members and their families knowledge & the tools to manage their health conditions.
Preventive health screenings and vaccinations Provide tailored support and referrals to community resources based on individual member needs.
Behavioral health support providing evaluation, treatment and counseling for BH conditions and social determinants of health. Supports members experiencing a transition between care settings.
Post discharge transition of care assessments evaluate health risks, care needs, and medication reconciliation. Care Managers coordinate care across healthcare providers and services.
Collaboration with the Interdisciplinary Care Team to support the care needs of the member.
Ensures members receive timely and appropriate care. Health Risk Assessments are performed to identify the medical, social and psychological needs of members.
Individualized care plans outline the services, treatments and interventions required to meet the members health goals. Care managers conduct a telephonic care management outreach call to members every month.
Engages members to participate in healthcare decisions, care goal setting and self –management of their health conditions. 43<br>
Outreach Assist members in managing chronic conditions like diabetes, heart disease, and COPD.
Provide members and their families knowledge & the tools to manage their health conditions.
Preventive health screenings and vaccinations Provide tailored support and referrals to community resources based on individual member needs.
Behavioral health support providing evaluation, treatment and counseling for BH conditions and social determinants of health. Supports members experiencing a transition between care settings.
Post discharge transition of care assessments evaluate health risks, care needs, and medication reconciliation. Care Managers coordinate care across healthcare providers and services.
Collaboration with the Interdisciplinary Care Team to support the care needs of the member.
Ensures members receive timely and appropriate care. Health Risk Assessments are performed to identify the medical, social and psychological needs of members.
Individualized care plans outline the services, treatments and interventions required to meet the members health goals. Care managers conduct a telephonic care management outreach call to members every month.
Engages members to participate in healthcare decisions, care goal setting and self –management of their health conditions. 43<br>
44
Pharmacy 32<br>
45
Table of Content Transition to 6 tier formulary for 2025
Explanation of LICS levels and copay
Pharmacy benefit update
Explanation of coverage determination, the formulary, and non-formulary drugs
Frequently asked questions 45<br>
Explanation of LICS levels and copay
Pharmacy benefit update
Explanation of coverage determination, the formulary, and non-formulary drugs
Frequently asked questions 45<br>
46
Tier 1 - contains lower costing generic drugs chosen by VillageCareMAX. These drugs have the same active ingredients as their brand-name counterparts.
Tier 2 - consists of medium costing generic drugs. These drugs also contain the same active ingredients as their brand-name counterparts.
Tier 3 - primarily consists of preferred brand name drugs that do not have generic equivalents available. VillageCareMAX selected these drugs based on their high overall value, considering their safety, efficacy, and cost compared to other brand name drugs on the market. Tier 3 also includes medium-high costing generic drugs.
Tier 4 - mainly includes non-preferred brand name drugs. It also encompasses high costing generic drugs and highest costing generic drugs, and generics new to market.
Tier 5 - is composed of all specialty drugs.
Tier 6 - is STAR measure drug. Prescription Tiers 46<br>
Tier 2 - consists of medium costing generic drugs. These drugs also contain the same active ingredients as their brand-name counterparts.
Tier 3 - primarily consists of preferred brand name drugs that do not have generic equivalents available. VillageCareMAX selected these drugs based on their high overall value, considering their safety, efficacy, and cost compared to other brand name drugs on the market. Tier 3 also includes medium-high costing generic drugs.
Tier 4 - mainly includes non-preferred brand name drugs. It also encompasses high costing generic drugs and highest costing generic drugs, and generics new to market.
Tier 5 - is composed of all specialty drugs.
Tier 6 - is STAR measure drug. Prescription Tiers 46<br>
47
2025 Pharmacy Benefit High-Level Update The Pharmacy Team will do a more in-depth training, so we’re going to do a high-level overview of the changes for 2025 VBID – VCM is electing to use the Part D flexibilities of the VBID model to allow D-SNP (plan 001) and D-SNP Flex (plan 003) members to have $0 copay on all Part D drugs (except enhanced drugs)
STAR Measure Drugs – For members enrolled in MAP (plan 002) and MHA (plan 004), a 6th Rx Tier has been added for STAR Measure drugs
STAR Measure drugs include certain medications for Type II Diabetes, Hypertension, and Cholesterol Reduction
These drugs will have a $0 copay for the member
Medicare Prescription Payment Plan (M3P) - CMS is requiring all prescription plans to allow members the option to pay for their out-of-pocket drug costs in a monthly payment instead of all at once at the pharmacy 47<br>
STAR Measure Drugs – For members enrolled in MAP (plan 002) and MHA (plan 004), a 6th Rx Tier has been added for STAR Measure drugs
STAR Measure drugs include certain medications for Type II Diabetes, Hypertension, and Cholesterol Reduction
These drugs will have a $0 copay for the member
Medicare Prescription Payment Plan (M3P) - CMS is requiring all prescription plans to allow members the option to pay for their out-of-pocket drug costs in a monthly payment instead of all at once at the pharmacy 47<br>
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Coverage Determinations and the Formulary Medications that are on the VillageCareMAX formulary are covered under Medicare Part D.
However, within the formulary, some medications must meet certain clinical criteria before VCM will pay for the medication.
Medications can have coverage determination requirements because of clinical rationale, cost-effectiveness, cheaper available formulary alternatives, or all the above.
Coverage determination requirements can include prior authorizations, step therapy, quantity limits, and other utilization management limitations.
A formulary exception request is a separate process that requires a different application.
Both applications are available on our website, https://villagecaremax.org 48<br>
However, within the formulary, some medications must meet certain clinical criteria before VCM will pay for the medication.
Medications can have coverage determination requirements because of clinical rationale, cost-effectiveness, cheaper available formulary alternatives, or all the above.
Coverage determination requirements can include prior authorizations, step therapy, quantity limits, and other utilization management limitations.
A formulary exception request is a separate process that requires a different application.
Both applications are available on our website, https://villagecaremax.org 48<br>
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Top Non-Formulary Drugs 2025 49<br>
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Quality 50<br>
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Quality and Value VillageCareMAX is committed to quality.
The VillageCareMAX Quality Improvement Program is a comprehensive program designed to conduct meaningful quality improvement activities across the organization aimed at improving member health outcomes, quality of care, services delivered and overall customer satisfaction.
We value the relationship between the Plan and the Providers who deliver high quality care and achieve quality results.<br>
The VillageCareMAX Quality Improvement Program is a comprehensive program designed to conduct meaningful quality improvement activities across the organization aimed at improving member health outcomes, quality of care, services delivered and overall customer satisfaction.
We value the relationship between the Plan and the Providers who deliver high quality care and achieve quality results.<br>
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Provider Improvement strategies VILLAGECAREMAX 4 GETTING APPOINTMENTS AND CARE QUICKLY Inform patients of expected wait times during check-in. Keep them informed if there is a delay. Communicate delays apologetically and offer to reschedule if necessary
Consider open access scheduling; allow a portion of each day open for urgent care and/or follow-up care.
Provide members streamlined tools and resources (links, apps, etc.) about benefits, providers, referrals, scheduling appointments, and costs
Consider alternative convenient sources of information, e.g., newsletter inserts, refrigerator magnets
Promote use of a secure online patient portal which allows patients access to their medical record and health care information of relevant to patient needs
Analyze appointment scheduling timeframes versus types of office visits to help minimize wait times DOCTORS WHO COMMUNICATE WELL Apply empathy, be personable and take interest in response to concerns, be kind, avoid condescending language or actions
Repeat the patient's concern and address questions directly and maintain direct eye contact
Provide thorough explanations, use written materials, illustrations and/or examples to help patients understand
Avoid medical jargon and technical language - use simple terms, tailor language to the patient's level of understanding
Train staff on how to answer questions clearly and resolve issues quickly; be consistency friendly, courteous and empathetic; minimize transfers and wait/on-hold times<br>
Consider open access scheduling; allow a portion of each day open for urgent care and/or follow-up care.
Provide members streamlined tools and resources (links, apps, etc.) about benefits, providers, referrals, scheduling appointments, and costs
Consider alternative convenient sources of information, e.g., newsletter inserts, refrigerator magnets
Promote use of a secure online patient portal which allows patients access to their medical record and health care information of relevant to patient needs
Analyze appointment scheduling timeframes versus types of office visits to help minimize wait times DOCTORS WHO COMMUNICATE WELL Apply empathy, be personable and take interest in response to concerns, be kind, avoid condescending language or actions
Repeat the patient's concern and address questions directly and maintain direct eye contact
Provide thorough explanations, use written materials, illustrations and/or examples to help patients understand
Avoid medical jargon and technical language - use simple terms, tailor language to the patient's level of understanding
Train staff on how to answer questions clearly and resolve issues quickly; be consistency friendly, courteous and empathetic; minimize transfers and wait/on-hold times<br>
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Helping Patients Complete Member Experience Surveys Who Can Help? • Patients’ Family Members or Friends • Patients’ Caregivers or Aides • Patients’ Daycare Employees • Patients Provider Office Staff 53 What help can be given to patients while completing the surveys?<br>
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2025 HEDIS® Measure Changes Documented Assessment After Mammogram: The percentage of episodes for members 40–74 years of age with mammograms documented in the form of a BI-RADS assessment within 14 days of the mammogram.
Follow-Up After Abnormal Breast Cancer Assessment: The percentage of episodes for members: 40–74 years of age with inconclusive or high-risk BI-RADS assessments that received appropriate follow-up within 90 days of the assessment.
Blood Pressure Control for Patients With Hypertension: The percentage of members 18–85 years of age who had a diagnosis of hypertension and whose most recent blood pressure was <140/90 mm Hg during the measurement period.
Intent: Two key modifications from the Controlling High Blood Pressure (CBP) HEDIS measure, which uses the Hybrid reporting method (including medical record review) and a denominator that may miss many people with hypertension who should be included in the measure. 54<br>
Follow-Up After Abnormal Breast Cancer Assessment: The percentage of episodes for members: 40–74 years of age with inconclusive or high-risk BI-RADS assessments that received appropriate follow-up within 90 days of the assessment.
Blood Pressure Control for Patients With Hypertension: The percentage of members 18–85 years of age who had a diagnosis of hypertension and whose most recent blood pressure was <140/90 mm Hg during the measurement period.
Intent: Two key modifications from the Controlling High Blood Pressure (CBP) HEDIS measure, which uses the Hybrid reporting method (including medical record review) and a denominator that may miss many people with hypertension who should be included in the measure. 54<br>
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2025 HEDIS® Initiatives Cologuard® - Partnering with Exact Sciences to close the COL-E measure.
Annual Wellness Visits (AWV): Working with Member Outreach and Risk to get members to complete the AWV. Many measures can be closed at these visits.
Triple weighted measures:
Glycemic Status Assessment (GSD):
Initiated a workgroup for members with HbA1c levels ≥8.0%.
Controlling Blood Pressure (CBP):
Initiated a workgroup for members with blood pressures ≥140/90. 55<br>
Annual Wellness Visits (AWV): Working with Member Outreach and Risk to get members to complete the AWV. Many measures can be closed at these visits.
Triple weighted measures:
Glycemic Status Assessment (GSD):
Initiated a workgroup for members with HbA1c levels ≥8.0%.
Controlling Blood Pressure (CBP):
Initiated a workgroup for members with blood pressures ≥140/90. 55<br>
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Annual Wellness Visits 56 The Medicare Annual Wellness Visit is a valuable opportunity to build strong relationships with patients, identify and document health risks, and complete a number of important preventive care activities.
The Medicare Annual Wellness Visit (AWV) is a once-a-year, prevention-focused visit between a patient and a primary care provider.
These visits allow providers and patients to update information about a patient’s health status, set shared goals for the year ahead, and close any gaps in care. •Code: G0438: Initial Annual Wellness Visit
Eligible after the member has had Medicare Part B for 12 months. •Code: G0439: Subsequent Annual Wellness Visit
Eligible annually after the “Initial Annual Wellness Visit.”<br>
The Medicare Annual Wellness Visit (AWV) is a once-a-year, prevention-focused visit between a patient and a primary care provider.
These visits allow providers and patients to update information about a patient’s health status, set shared goals for the year ahead, and close any gaps in care. •Code: G0438: Initial Annual Wellness Visit
Eligible after the member has had Medicare Part B for 12 months. •Code: G0439: Subsequent Annual Wellness Visit
Eligible annually after the “Initial Annual Wellness Visit.”<br>
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Resources 59<br>
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Information Sites Listed below are our information sites for additional resources.
VillageCareMAX Website: https://www.villagecaremax.org
Provider Portal: https://vcm.guidingcare.com/AuthorizationPortal
Provider Manual/Quick Reference Guides: https://www.villagecaremax.org/provider-manual
Provider Online Search: https://providersearch.villagecaremax.org
Provider Demographic Update Form: https://www.villagecaremax.org/providers/provider-demographic-change-form
VillageCareMAX Lead Form: https://d2mcoh0vajf3v0.cloudfront.net/production/public/files/docs/ForProviders/2022/Provider_Manual/FINAL_VCM_Provider_Manual_20220620.pdf#page=119 60<br>
VillageCareMAX Website: https://www.villagecaremax.org
Provider Portal: https://vcm.guidingcare.com/AuthorizationPortal
Provider Manual/Quick Reference Guides: https://www.villagecaremax.org/provider-manual
Provider Online Search: https://providersearch.villagecaremax.org
Provider Demographic Update Form: https://www.villagecaremax.org/providers/provider-demographic-change-form
VillageCareMAX Lead Form: https://d2mcoh0vajf3v0.cloudfront.net/production/public/files/docs/ForProviders/2022/Provider_Manual/FINAL_VCM_Provider_Manual_20220620.pdf#page=119 60<br>
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Questions 61<br>