1. Medicare-Health Plan Reimbursement Plan Project Patrick O’Reilly Masspro Mary Ann Preskul-Ricca Massachusetts Association of Health Plans

2. Health Plan Immunization Process  Health Plans typically use multiple interventions including:  Educate physicians - discuss at medical group meetings, physician newsletters, mailings with roster of target patients  Educate members - member newsletters, postcard mailings, posters, surveys  Hold flu shot clinics at Health Plan/Physician Offices  Provide incentives for physicians who increase immunization rates

3. Restatement of the Problem  Community Perspective There is decreasing value in collecting data for Medicare reimbursement for flu shots when increasing numbers of claims are rejected because the beneficiary is a member of a Health Plan.

4. Restatement of the Problem  Health Plan Perspective Immunizing seniors is a priority for Medicare Health Plans. Though the Health Plans encourage seniors to contact their physician offices for flu shots, many seniors continue to receive their shots at community clinics. Capturing that immunization information has been difficult.

5. Pilot Project: 1997 Eight Community Agencies Goal: To determine the feasibility of community agencies collecting and submitting data on Health Plan members they immunize, and of the Health Plans to efficiently process that information and provide the agencies with reimbursement at the Medicare rate.

6. Medicare Plan Pilot Project Participants  Health Plans  Aetna U.S. Healthcare  Blue Cross and Blue Shield of MA  Fallon Community Health Plan  Harvard Pilgrim Health Care  Tufts Health Plan  United HealthCare of New England

7. 2009 Medicare Advantage Plan Participants  Health Plans  Blue Cross and Blue Shield of MA  Fallon Community Health Plan  Harvard Pilgrim Health Care  Health New England  Senior Whole Health  Tufts Health Plan 7

8. Pilot Project Results Community agencies:8 Number of clinics held:106 Number of individuals immunized:12,937 Number of claims submitted to Health Plans: 1,639 (13%)

9. Project Assessment Community Agencies  Information was easy to collect but took longer to collect than in the past  There was difficulty in obtaining health insurance numbers  The deadline for submission of claims (Dec. 15) was difficult – would like more time

10.  Recommendations  More clerical staff is needed at clinics  Because there are a number of different plans, it would be helpful to have a copy of the plan member cards at each clinic site  Need to work more closely with the Health Plans to help participants understand which health plan they are enrolled in / Project Assessment

11.  Health Plan Recommendations  Health Plans need to develop more efficient ways of identifying the Primary Care Providers (PCP) of Medicare Plan members who receive flu shots at community clinics  Plans need to find a way of providing the immunization data from the community clinics to these PCPs

12. Program Following Pilot  Program opened to all community agencies that bill Medicare for flu immunizations  Pneumococcal immunizations added to the program in 2000

13. Current Program Process  Identify agencies that have or intend to bill Medicare for immunizations  Mail a recruitment letter “Ground Rules” and participation form  Receive and develop data base for participating agencies  Conduct a billing workshop  Distribute reimbursement forms

14. Program Process: Ground Rules  Expectations for Community Agency  Expectations for Participating Health Plans  http://www.mahp.com/resources/MedicareReimbursement.html http://www.mahp.com/resources/MedicareReimbursement.html

15. Participation by Community Agencies Number of Agencies

16. Data Collection Process Flu Clinic Data Health Plan Carrier/FI Community Agency

17. Growth of Reimbursement 17 Reimbursement Amount ?

18. Benefits for Health Plans  Offers plan members increased access to an influenza immunization  Provides an alternative to a physician’s office visit in order to receive an influenza immunization  Provides data on members immunized in community settings  An example of a voluntary community benefit that has value to the community agencies, to Medicare beneficiaries and to the health plans 18

19. Barriers for Health Plans  Since the program falls outside of the regular claims process, it has been necessary to set up a separate claims process.  Linking immunization data to the beneficiaries’ primary care practitioner and their record keeping has been difficult as it is a very time consuming process at this stage. 19

20. 20 Benefits for Community Agencies  Eliminates the frustration of not being able to obtain reimbursement for immunization of Medicare health plan members.  Where reimbursement can be placed in a revolving fund, it can be used to purchase immunization supplies and additional vaccine, or used for other departmental needs.

21. 21 Benefits for Community Agencies  Where a revolving fund is not available, reimbursement can be used to support other programs in the town.  For non-health department community agencies, the reimbursement helps cover the costs of the program, and supports other agency programs.  Increases access to influenza and pneumococcal immunization to elders who are members of a Medicare health plan.

22. Barriers for Community Agencies  More labor intense; need for additional training for volunteers  Process of collecting information may confuse elders if they think the influenza immunization is free  Elders do not always know they are a health plan member 22

23. Lessons Learned  Process  Built on established trust  Partnership between Masspro and MAHP  Workshops established a better understanding between community agencies and health plans  Met needs of both Health Plans and community agencies  Accomplished in a short time frame  The issues and problems identified are solvable

24. Conclusions  An effective collaborative relationship can be established among community agencies, Health Plans and the state health department  Community agencies are able to collect and provide data to health plans on members they immunize.  Health plans can process the claims information and provide the community agencies with reimbursement.

25. Contact information  Patrick O’Reilly  poreilly@maqio.sdps.org poreilly@maqio.sdps.org  Mary Ann Preskul-Ricca, MAHP, mapr@mahp.com 25