November 2023

 Two new RSV vaccinations are available, and vaccination recommendations are based on shared clinical decision-making.

Respiratory Syncytial Virus (RSV) is a common virus that typically circulates from October through March. RSV generally causes mild cold-like symptoms. However, infants and older adults may experience serious lower respiratory tract infections. Additionally, some patients could get RSV multiple times. In patients over 65, RSV causes up to 160,000 hospitalizations and 10,000 deaths annually, similar to many flu seasons.

There are now two RSV vaccines licensed for use in adults aged 60 years and older in the United States: RSVPreF3 (Arexvy, GSK) and RSVpreF (Abrysvo, Pfizer). The Centers for Centers for Disease Control and Prevention (CDC) recommends that adults 60 years of age and older may receive a single 0.5ml IM[JF1]  dose of RSV vaccine using shared clinical decision-making (SCDM). This means that health care providers and their patients should have a conversation to determine if RSV vaccination will be beneficial. This recommendation differs from routine age-based and risk-based vaccine recommendations for which the default decision is to vaccinate all persons in a specified age or risk group.

Under SCDM, there is no default. Instead, the decision is individually based and informed by discussions between the patient and health care provider (anyone who provides or administers vaccines, including primary care physicians, specialists, physician assistants, nurse practitioners, registered nurses, and pharmacists). The decision may be informed by a patient’s health status, their risk of severe RSV disease (see Risk Factors below), the health care provider’s clinical judgment, the patient’s preferences, the safety profile of the RSV vaccine products and other factors. The SCDM recommendation for RSV vaccination is intended to allow providers and patients flexibility based on what is best for each individual patient. 

Risk factors for severe RSV disease

Epidemiologic evidence indicates that persons aged 60 years and older who are at highest risk for severe RSV disease and who might be most likely to benefit from vaccination include those with chronic medical conditions such as:

• Cardiopulmonary disease,
• Kidney disorders,
• Liver disorders,
• Neurologic or neuromuscular conditions,
• Hematologic disorders,
• Diabetes mellitus, and
• Moderate or severe immune compromise (either from a medical condition or receipt of immunosuppressive medications or treatment)

Others who may benefit include individuals who:

• are frail;
• are of advanced age;
• reside in nursing homes or other long-term care facilities; and, 
• have other underlying conditions or factors that the provider determines might increase the risk for severe respiratory disease.

Tipsheet: RSV vaccines and monoclonal antibody treatment

For information on RSV vaccines and monoclonal antibody treatments, including coverage and billing, view this helpful tip sheet.

Independent Health will add generic versions of the products to our formularies to maintain care.

In June, GlaxoSmithKline (GSK) notified the U.S. Food and Drug Administration (FDA) that they will discontinue branded Flovent HFA (all strengths) and Flovent Diskus (all strengths) on December 31, 2023.  

To ensure that patients still have access to fluticasone propionate, GSK will continue to manufacture an authorized generic of Flovent HFA and plans to launch an authorized generic of Flovent Diskus in late 2023. 

In response to these discontinuations, Independent Health will add the authorized generics of these products to our formularies for all plans as noted below:

• Fluticasone propionate inhalation aerosol (generic Flovent HFA) will be added to our formularies effective November 1, 2023.
• Fluticasone propionate inhalation powder (generic Flovent Diskus) will be on our formularies effective January 1, 2024 or as soon as available.

It is important for patients to continue to take their medication. For most patients, their Flovent prescription will automatically be substituted for the generic at their pharmacy. If you wrote your patient’s previous Flovent prescription as “DAW,” you will need to send a new prescription to their pharmacy.

For the most up to date information on covered products, please refer to the Drugs Covered page on our website.

This article discusses important coverage requirements and pharmacy benefits for youth in foster care.

Network providers with Independent Health may be in a position to provide trauma-informed care to Medicaid Managed Care (MMC) youth in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCA).

Providers must provide for and coordinate services for youth in foster care in compliance with the New York Medicaid Program 29-I Health Facility Billing Manual and the Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care guidance documents, which are  available here. 

The pharmacy benefit requirements for youth placed in foster care include, but are not limited to, rapid replacement of medically necessary prescriptions and transitional fills for youth newly placed in foster care. 

Effective April 1, 2023, the pharmacy benefits for MMC members, including youth placed in foster care, transitioned to NYRx, the Medicaid Pharmacy program. However, physician-administered drugs, Durable Medical Equipment, prosthetics, orthotics, and supplies are still covered by Independent Health when billed as a medical or institutional claim. View the Pharmacy Procedure Code manual here. 

Upon placement into Foster Care, a child is required to have an Initial Medical Assessment within the first 30 days of the child/youth’s placement. The child may utilize any primary care physician (PCP) or qualified practitioner in the MMC Plan’s network for the purposes of this Initial Medical Assessment.

For ongoing primary care visits, if there is a discrepancy with the assigned PCP on the MMC member ID card, do not turn the youth away; instead, please immediately call Independent Health at (716) 250-7183 to rectify this matter.

Make sure to get your gaps-in-care corrections into Independent Health if you find inaccuracies for certain reasons.

The last day to submit 2023 gap-in-care corrections for medical record documentation to Independent Health through our provider portal is Wednesday, January 3, 2024 at 6 p.m.  

After this date, we will no longer accept gap-in-care corrections for the 2023 calendar year.  

We will inform participating providers when we will begin accepting gap-in-care corrections for 2024.

The Gaps in Care Correction process allows for medical record documentation to be submitted to “correct” inaccuracies in quality measure results due to a variety of reasons, including: 

• Encounters or lab values not available to the health plan
• Exclusions from a historical event (e.g., mastectomy)
• Service that was rendered under a different payer

If the correction is accepted, it will be reflected in an update to your quality rates (and Independent Health's), which allows for:

• A more accurate depiction of the quality of care that was rendered
• More accurate quality program reporting
• More targeted quality improvement effort

View the Gaps in Care Correction Process User Guide, view a webinar and learn more about submitting correction requests in our secure provider portal here. (This information is in the Quality section under the Resources tab selection.) 

If you have questions about the gaps in care correction process, performance reports or anything related to our provider portal:

Contact your Independent Health Physician Engagement Specialist or Email ProviderPortal@independenthealth.com

Portal accounts inactive since 2022 will be terminated.

Self-funded and commercial members will be assigned new ID numbers that begin with W.

Throughout the year, the Health Care Services and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.

Have you and your staff completed the required Fraud, Wast & Abuse and Cultural Competency Training? If not, here's how...

While there were no pharmacy or formulary updates for November, we encourage our participating providers to view the Third Quarter updates.

ACHP Plans Continue to Excel in CMS Quality Star Ratings - Alliance for Community Health Plans, Oct.. 25, 2023

Independent Health is WNY's only 5-Star Rated Medicare Advantage Plan for 2024 - Oct. 16, 2023 news release