December 2024

HIV testing must be offered at least once as a routine part of health care to all patients age 13 or older receiving primary care services at an outpatient clinic or primary care services..

HIV testing must be offered at least once as a routine part of health care to all patients age 13 or older receiving primary care services at an outpatient clinic or primary care services from a physician, physician assistant, nurse practitioner or midwife.

IMPORTANT points to remember:

• NYS Public Health Law mandates the offer of HIV testing to all patients age 13 or older.
• The offer of HIV testing is most effective when it is presented as a clinical recommendation of the health care provider.
• The provider must document the offer of HIV testing in the patient medical record.
  • Facilitate early prenatal care with universal opt-out HIV testing at the first prenatal visit and repeat HIV testing in the third trimester.

The health care provider must provide information about HIV orally, in writing, through signage or in any other patient-friendly audio-visual format. Placing the NYSDOH HIV testing clinic poster in a visible location or providing patients with the NYSDOH patient brochure on HIV testing are simple ways of conveying this information to patients.

Information to be provided to the patient prior to HIV testing before conducting diagnostic HIV testing.

The key points of information that must be provided are:

• HIV testing is voluntary, and all HIV test results are confidential (private);
•  HIV can be transmitted through unprotected sex, sharing needles, childbirth or breastfeeding;
• Treatment for HIV is very effective, has few or no side effects and may involve taking just one pill once a day;
• Partners can keep each other safe by knowing their HIV status and getting HIV treatment or taking HIV pre-exposure prophylaxis (PrEP).
• Not sharing needles and practicing safer sex will help protect against HIV, hepatitis C and other STDs.
• It is illegal to discriminate against a person because of their HIV status and services are available to help address discrimination;
• Anonymous HIV testing (without giving your name) is available at certain public testing sites;
• HIV testing is a routine part of health care, but patients have the right to decline an HIV test. Testing should not be performed if the patient objects.

Information and Resources

When testing indicates a diagnosis of HIV infection, the person ordering HIV testing or their representative must provide the patient with the final interpretation of diagnostic testing, and, with the patient’s consent, schedule an appointment for follow-up HIV medical care. This must be documented in the patient’s medical record.

For more information and resources, please visit

• HIV Testing.
• HIV Testing, Reporting and Confidentiality in New York State 2023 Update: Fact Sheet & Frequently Asked Questions

Data suggests that beginning at 50 years, adults have an increased risk of pneumococcal infections, which can lead to pneumonia, meningitis, and bloodstream infections. 

The Centers for Disease Control and Prevention (CDC) has updated its recommendations for pneumococcal vaccinations, aiming to enhance protection against pneumococcal disease across various age groups and risk categories. The recommendation released on October 23, 2024, lowered the age for pneumococcal vaccination from 65 to 50 years old.

Data suggests that beginning at age 50 years, adults have an increased risk of pneumococcal infections, which can lead to serious infections like pneumonia, meningitis, and bloodstream infections. This is regardless of the presence or absence of risk factors. Being aware of these changes is crucial for healthcare providers to ensure optimal patient care and adherence to the latest guidelines. 

Key recommendations

Children under 5 years:

• Routine Vaccination: Administer a 4-dose series of either PCV15 or PCV20 at 2, 4, 6, and 12 to 15 months of age.
• Catch-Up Vaccination: For children who miss their shots or start the series late, follow the CDC’s catch-up schedule to ensure they receive the necessary doses.

Adults 50 years and older: 

• Routine Vaccination: All adults aged 50 and older should receive either PCV15, PCV20, or PCV21.
  • If PCV15 is used, it should be followed by a dose of PPSV23 at least one year later or 8 weeks later in adults with immunocompromised conditions, cochlear implant or cerebrospinal fluid leak.
• Shared Clinical Decision-Making: For adults 65 and older, vaccination with PCV20 or PCV21 can be considered based on individual health status and risk factors.
  • They can get either PCV20 or PCV21 if they’ve received both PCV13 (at any age) and PPSV23 (at or after 65 years of age). It is recommended to wait at least five years between the PCV13 or PPSV23 and PCV20 or PCV21. 

Adults 19 to 50 years with certain risk factors:

• Vaccination Indications: Adults in this age group with underlying conditions such as diabetes, chronic liver disease, or immunocompromising conditions should receive pneumococcal vaccines.
• Vaccine Options: PCV15 followed by PPSV23, or PCV20 alone, are recommended based on the patient’s vaccination history and risk profile. 

Implementation tools

PneumoRecs VaxAdvisor: A free app provided by the CDC to help healthcare providers determine the appropriate pneumococcal vaccines for their patients. Available for iOS, Android, and as a web-based tool. Here is the link to the web-based tool. 

Job Aids: The CDC offers various job aids to simplify the interpretation of vaccination schedules and assist in clinical decision-making.

For more information and resources, visit:

• Pneumococcal Vaccine Timing for Adults
• PCV20 or PCV21 Vaccination for Adults 65 or Older
• CDC News Release: CDC recommends lowering the age for pneumococcal vaccination from 65 to 50 years old.
• CDC web resources on pneumococcal vaccination

At-home sleep tests (HSTs), also known as Unattended Sleep Studies or Home Sleep Apnea Tests (HSAT), are used to help diagnose sleep disordered breathing conditions in the home setting when medically appropriate. 

According to the NYS Medicaid August 2024 Update, New York State Medicaid Managed Care plans, including Independent Health’s MediSource, MediSource Connect and New York Essential Plan will cover in-home sleep studies beginning December 1, 2024.  

Independent Health will require prior authorization for code 95800 and will follow the New York State Medicaid coverage criteria.  The ordering provider must meet the standards outlined below:

Criteria:

• Member must be 18 and over.  Please note that Child Health Plus is excluded from coverage.
• Coverage is limited to members who would experience difficulty traveling to a sleep lab for a lab-based sleep test (polysomnography) due to mobility issues [e.g., members who need assistance with ambulation or use a Durable Medical Equipment (DME) to ambulate, such as a wheelchair or a walker] as long as the home sleep study is a medically appropriate alternative member.
• For members who meet the above coverage criteria, healthcare providers should use their clinical judgment to determine if an HST is a medically appropriate alternative to a lab-based sleep test (polysomnography).
• Additionally, home sleep study raw data must be reviewed and interpreted by a Sleep Medicine specialist who is either board-certified or board-eligible in Sleep Medicine. 

It is imperative that health care providers use good clinical judgment when determining if a home sleep study is a medically appropriate alternative to a lab-based sleep test (polysomnography).

Limitations:

• Home sleep studies can only be billed once per year. If a repeat home sleep study is needed before the one-year mark, persuasive medical evidence will be required.

Repeat studies may be indicated for the following situations:

• If the first study was technically inadequate due to equipment failure.
• If the member did not know how to operate the HST equipment correctly or did not sleep for a sufficient amount of time to allow a clinical diagnosis.

The following must be documented in the medical records of the patient:

• Documentation of informed consent by the patient.
• Documentation supporting the medical necessity for sleep testing must be maintained in the clinical file of the ordering physician.
• Documentation of patient history, physical exam, and healthcare provider assessment that prompted the need for an HST must be in the file prior to HST.
• Documentation of the HST outcome/test results.

Billing instructions

• Orders for sleep testing are limited to Sleep Medicine specialists who are fellowship-trained and board-certified/board-eligible and may include family medicine physicians, internal medicine physicians, pediatricians, psychiatrists, neurologists, pulmonologists, and otolaryngologists.  See billing instructions below:
• Do not report Current Procedure Code (CPT) code "95800", in conjunction with CPT codes "93041" through "93227", "93228", "93229", "93268" through "93272", "95801", "95803", and "95806".
• Watchpat must be billed as CPT code "95800".
• If a sleep study is performed for less than six hours, it should be billed with modifier "52".
• Bundled under the one rate includes cost of equipment, the assessment, and interpreting results.

Reimbursement:

Pre-authorization requirements for commercial products will focus on individuals with severe obesity and comorbid conditions as of Jan. 1.  

Recognizing the importance of a doctor’s expertise to find the right approach to manage weight loss goals, Independent Health has a weight-loss medication policy for our commercial plan members that requires preauthorization for GLP-1s.

We continue to track growing utilization and costs of GLP-1 medications used for weight loss. Based on the expected growth of GLP-1 utilization, and to be consistent with other health plans, we will update the policy requirements for GLP-1 coverage and modify the formularies for commercial products (except for the Federal Employees Health Benefits Plan, or FEHB, which has its own requirements). 

Therefore, to help manage costs and improve value for our members, Independent Health is making changes to the preauthorization process and formulary in 2025 for commercial products and the Essential Plan: 

• Policy update effective Jan. 1, 2025: Among other changes to the policy, the prior authorization criteria will include a BMI of 40kg/m2 or greater in the presence of at least two comorbid conditions, including but not limited to coronary heart disease, atherosclerotic diseases, hypertension, dyslipidemia osteoarthritis, sleep apnea, polycystic ovary syndrome), or BMI of 30kg/m2 or greater with established cardiovascular disease.

The policy effective Jan. 1, 2025, has additional changes, including weight loss and other requirements; it is important to review the policy for these updates.  The policy will be posted by Dec. 1, 2024.

• Formulary changes effective March 1, 2025: For your awareness, Wegovy, Saxenda and Zepbound will become non-formulary for Drug Formularies I, II, III, and the Essential Plan Formulary.  Contrave will be the only formulary weight loss product.  Please note, the above policy will apply to formulary exception requests. 

We will post this policy 30 days before March 1, 2025. 

Additional information

• We continue to require individuals to complete a six-month formalized weight management program that was added to the policy for September 2024. 
• Members who are currently taking these medications will be re-assessed when their authorization is due for renewal. Re-authorization will be based on the new policy; for example, individuals whose BMI is less than 40 might not obtain authorization.

The coverage policy is consistent with other commercial health plans locally and across the country.

We recognize that some members have successfully maintained a healthier weight with these medications; however, we are very concerned at the cost of these medications and the financial impact they have on premiums and health care in general, so we have had to make the difficult decision to focus these weight loss medications on our members with severe obesity who have a higher risk for obesity-related complications and comorbidities.  

The Quality Performance Committee has reviewed and approved updates to guidelines and has updated links to resources.

Independent Health's Quality Performance Committee has reviewed and approved the Clinical Practice Guidelines (CPG’s), which have been updated where necessary.  Changes include adoption of the following guidelines:

• Adopted ADHD CDC guideline Clinical Care of ADHD | Attention-Deficit / Hyperactivity Disorder (ADHD) | CDC, May 2024
• Adopted Depression APA guideline Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts (apa.org), Sept 2024

The following website links have been updated:

• Smoking Cessation intervention guideline link updated: Smoking and Tobacco Use | Smoking and Tobacco Use | CDC, 2024
• Diabetes Standards of Care: Standards of Care in Diabetes | American Diabetes Association, 2024
• Kidney Disease: American Journal of Kidney Diseases (ajkd.org), 2024
• Child and Adolescent Immunization Schedule by Age (Addendum updated June 27, 2024) | Vaccines & Immunizations | CDC , 2024
• Opioids for Chronic Pain - Guidelines for Prescribing Opioids for Chronic Pain 2022 CDC Clinical Practice Guideline at a Glance | Overdose Prevention | CDC
• Hepatitis Clinical Screening and Diagnosis for Hepatitis C | Hepatitis C | CDC, Dec 2023

The updated clinical practice guidelines are posted in the provider portal under the Policies and Guidelines tab.

Real-Time Prescription Benefit through Surescripts, which allows provider practices to view medication costs and therapeutic alternatives through their Electronic Health Record (EHR) systems. 

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

Stay up-to-date on Independent Health's pharmacy policies and formulary updates.