For more information call us at 1-800-327-8613 or visit www.MCCofFL.com

Issue 6 | Fall 2016

A Message from Gregory LueckHappy Holidays! As we enter into the season of gratitude and appreciation, Magellan Complete Care would like to thank you for your collaboration, continued support, and dedication to our organization. We truly appreciate the exceptional level of service and care that you have provided to our members throughout the year. We recognize that our network of providers and service organizations play a crucial role in the progression and overall health outcomes of our members—along with the success our health plan.

As the holiday season and new year approaches, it is important that we stay mindful and continue to strive on improving HEDIS outcomes, as it is a reflection of our collaborative focus on providing remarkable quality service. Our team of clinicians, field staff, peer support navigators, community outreach and provider support specialists are here to support you in delivering the highest level of coordinated care for our members.

We look ahead to 2017 as another year and opportunity to work together to continue our mission of improving the health and lives of our members, their families and the communities we serve.

~ Gregory Lueck, VP, Chief Operations Officer

5 Ways technology can enhance your practiceMagellan Complete Care supports the use of technology. Providers should consider incorporating the use of secured technology into practice to make accessing services more convenient for members. Examples include:

• E-visits—email communication between providers and members after a face-to-face takes place

• E-prescribing—sending a prescription directly to the member’s pharmacy

• Refill reminders—email notification to remind members to refill their medications

• E-appointment—allows members to schedule appointments electronically

• Online personal health records—enables members to keep track of their personal health information

Magellan Complete Care of Florida

Provider Newsletter

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Magellan Complete Care of Florida’s Quality ImprovementMagellan Complete Care of Florida’s Quality Improvement (QI) Program is committed to work with our doctors to find ways to give better care and services to our members.

Every year, the QI Program looks over our current activities to see what we can do better. A few of these include:

• Checking the education and training of doctors before they join our group

• Keeping track, looking into and answering any concerns given to us

• Encouraging members to get preventive health screenings such as; mammograms, pap smears, eye exams for those who have diabetes and regular immunizations

• Setting and reviewing standards so members can reach doctors by phone, make quick appointments, and have more choices of doctors near their homes

Areas we’ve worked on in 2015:These baselines were gathered and made for year to year comparison

• Increase the number of members 1 to 20 years old who had at least one preventive dentist visit during the year.

• Increase the number of members that completed a diabetes screening in Regions 10 (Broward County) and 11 (Miami-Dade and Monroe Counties) who have schizophrenia or bipolar disorder that are using antipsychotic medications

• Increase the number of adult members’ overall satisfaction of Magellan Complete Care

Areas we’re working on in 2016:• Continue to track and trend results from doctor surveys

• Doctor access availability audits for doctor meeting requirements, including collecting data for tracking and trending

• Educate doctors on the importance of compliance in appointment access standards with sick care, emergency care, primary care, initial prenatal care and initial family planning

• Educate members and doctors by newsletter articles

• Review information quarterly for correct reporting

For more information, please call the Quality Department at 1-800-327-8613.

Second medical opinion

Members have the right to a second medical opinion. If the organization cannot provide a second opinion from an in-network provider, arrangements can be made for a second opinion outside of the network. Please contact our Health Services department at 1-800-327-8613 for a prior authorization request.

Reminders for important information

For specific information on:

• Complaint or Grievance Process

• Covered Services

• Directory Availability

• Hours of Operation (no less than rule)

• Member and Provider Rights and Responsibilities

• Prior Authorizations

• Privacy Health Notices

• Information Updates

• Reporting Suspected Fraud, Waste & Abuse

Please visit MCCofFL.com where you can access this information online as well as access our Provider Handbook.

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Affirmative statement about UM incentivesMagellan Complete Care of Florida gives a statement to all members, doctors, and employees who make utilization management (UM) decisions, affirming the following:

• Utilization Management decision making is based on appropriate care, service and coverage

• Doctors and other individuals are not rewarded for not giving service or care to members

• Utilization Management decision makers (doctors, professionals, and employees) do not receive money or other gifts to encourage decisions that result in under usage

If you have any questions about this Affirmative Statement, please call Magellan Complete Care at 1-800-327-8613.

Magellan Complete Care and NAMI walks for mental health awareness!

Magellan Complete Care is a proud sponsor of this year’s NAMIwalks, located in Broward and West Palm Beach county. The Magellan Complete Care team along with many supporters, recently participated in the 5K NAMIWalks event to promote and create awareness of recovery and

shift the stigmatic perspectives that follow people dealing with a mental health disorder.

NAMIwalks is NAMI’s largest and most successful mental health awareness and fundraising event in the country! The National Alliance on Mental Illness (NAMI) is a mental health organization that is dedicated to building better lives for those who are dealing with mental illnesses. They provide support, education and advocacy for the millions of Americans affected by mental illness. For more information on NAMI or to participate in an upcoming NAMIwalks, please visit their website at www.nami.org

Information derived from www.nami.org

Utilization Management criteria

You can call us if you have any questions about how we determine benefit coverage for our members. Decisions for approved services are based only on the appropriateness of care, service and existence of coverage. Utilization Management staff and Medical Directors are not financially or otherwise compensated to encourage underutilization or denials. For more information, please refer to the provider handbook on MCCofFL.com under Provider Handbook. If you would like a copy of the criteria that is used to determine how services are covered, please contact customer service at 1-800-327-8631.

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Pharmacy preferences and restrictionsOur preferred drug list (PDL) covers and includes all the medications that are included in the Florida Medicaid Preferred Drug List. You can visit our website at MCCofFL.com to find the link to the current Medicaid Preferred Drug List. There you can also find the Changes Summary Report for information on specific preferred drugs, generic substitutions and changes made to the preferred drug list.

The Florida Medicaid Preferred Drug List is subject to change based on the consideration and recommendations made by the Pharmaceutical and Therapeutics (P&T) Committee and the Agency for Health Care Administration.

Drugs on the preferred drug list (PDL) do not need prior authorization. As a doctor, you may request an exception for drugs that are not on the PDL.

How to request a drug exceptionIf you feel that your patient needs a medicine that is not on the PDL, you may Request a Drug Exception. Some reasons you may request an exception are:• The patient has allergies to the other drug

options on the list• The approved drug(s) was not effective • The patient cannot take the approved drug

If you have any questions or would like more information, please call us at 1-800-327-8613.

Success story

A member was dealing with multiple psychiatric problems due to seeing an inmate murdered while he was in prison. Because of this traumatic experience, he developed agoraphobia and could not leave his room without the fear of feeling unsafe. Since he was unable to sit in the waiting room for more than a few minutes to see a doctor, he began to receive support regularly by phone.

The care manager worked closely with the member and encouraged him to see a psychiatrist to get proper care. The psychiatrist was able to work with the member and through therapy, the member was finally able to get out of the house and enjoy life without feeling threatened.

This member is now regaining control of his life and is also looking into going back to school. He is very grateful and appreciative to all of the staff involved in helping him get the care that he needed to change his life around.

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HEDIS Gaps in Care available onlineOur online Provider Portal is a useful resource for obtaining your patient’s HEDIS Gaps in Care.

Here are 4 easy steps to accessing your patient’s HEDIS Gaps in Care reports:

1. Log on to the Provider Portal

2. Under My Reports, click on Plan Specific Reports

3. Below the IBM Cognos Navigator main heading, click on MCC Group Provider PCP Roster

4. Select the month by using the drop down box on the upper left and click Finish

Your Magellan Complete Care Primary Care Provider Roster by Group MISID will be displayed with the HEDIS Gaps in Care identified on the far right column.

Through the Primary Care Provider roster on the Provider Portal, you are able to identify all members assigned to your practice who have gaps in care. You can also filter by the level of risk types such as; ultra-high, high, moderate and low risks.

If you need assistance or are experiencing log in issues, please call us at 1-800-327-8613. To reset your password, send an email to flmcccustomerservice@magellanhealth.com and use PASSWORD RESET FLORIDA in the subject area.

National Impaired Driving Prevention MonthThe month of December is recognized as National Impaired Driving Prevention Month. For many people, ‘holiday cheer’ includes attending parties and gatherings where alcohol is present. Impaired driving fatalities are heavily increased during the holidays.

Although many people recognize that alcohol-impaired driving can lead to fatal tragedies—they are sometimes unaware that drugged driving is just as dangerous.

A survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2010 showed that 13.2% of people aged 16 and older drove under the influence of alcohol and 4.3% drove under the influence of illicit drugs during the previous year.

Here are a few tips you can use and share with friends, family and patients to help them stay safe.

Plan aheadDesignate a sober

driver ahead of time

Help your guests be responsible

Always offer non-alcoholic beverages

Take the keysDo not let friends drive

impaired and do not ride with a person who may be under the influence

of alcohol or drugs

Buckle upMake sure to always wear your seatbelt

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November 19th—International Survivors of Suicide DayAccording to the National Alliance on Mental Illness (NAMI), studies have showed that over 90% of people that die from suicide have a diagnosable mental health condition. Suicidal thoughts and attempts should be taken seriously. It is important to make sure that those who are at risk of suicide are identified and receive proper care.

Assessing and managing the suicidal patient:When should an assessment be conducted?

• At intake on any patient with a psychiatric complaint, history of non-suicidal self-injuries, previous suicide attempt, mental illness diagnosis or substance use disorder

• When a patient experiences sadness, low mood, recent loss, hopelessness or having no purpose

• When a patient displays extreme mood swings

• When a patient acts anxious, agitated, reckless, shows rage or talks about seeking revenge

• At each subsequent session as long as the patient remains at risk

• Any time a patient has any other identified potential risk factors

How do I assess ideation and risk?

• At minimum, ask directly for presence and nature of suicidal thoughts

• Determine frequency and circumstances; characterize thoughts as passive ideation (“I would be better off dead”) or active ideation with a plan (“I am planning to shoot myself”)

• Make use of available assessment tools, e.g., the Scale for Suicide Ideation (SSI), Beck Scale for Suicide Ideation (BSS) or Columbia-Suicide Severity Rating Scale (C-SSRS)

• Determine if there is current intent or a plan

• Ask for plan details, including rehearsals

• Assess availability and lethality of means

• Determine if there’s a history of thoughts, wishes, impulses, self-injuries or suicide attempts

• Assess attitude, beliefs and values about suicide

• Ask patient about barriers to suicide, reasons for living and dying

• Consider and be sensitive to the different cultural views regarding suicide

• Determine if anything is different this time that will raise or lower risk

• Determine if patient shared ideation with anyone

• Identify any supportive person who might be helpful in reducing the risk.

These risk factors need to be weighed by the amount of risk factors, recent hospitalizations, access to weapons, active psychosis, recent life stress events, social isolation, recent or past suicide attempts, newly diagnosed with serious medical problems, of advanced life, serious mental illness diagnosis, etc.

How do I support the suicidal patient?When risk appears severe and imminent, a medical emergency requires immediate action and intensive medical treatment, usually in a psychiatric hospital setting with close observation. Take direct, appropriate action by calling 911 for emergency services or contact Magellan. If risk does not appear severe and imminent:

• Mitigate, eliminate risk factors

• Strengthen barriers and reasons for not committing suicide

• Establish a therapeutic alliance

• Develop outpatient support, including a family support plan

• Treat underlying conditions

• Address any abuse of substances.

Additional information on Suicide Prevention can be found at: zerosuicide.sprc.org and www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Suicide

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Utilization Management denialsAs a participating practitioner, you have the right to discuss a Utilization Management denial and a potential denial with a Utilization Management physician. Magellan Complete Care provides the member and requesting provider with a written notice of action. The notification includes criteria used for making the determination and is based on a template provided by the Agency of Health Care Administration (AHCA) including the following:

1. The action that Magellan Complete Care or it’s subcontractor has taken or intends to take.

2. Reason for the action

3. The member or provider’s right to file an appeal with Magellan Complete Care

4. The member’s right to request a Medicaid Fair Hearing

5. Procedures for exercising the rights specified in the notice

6. The circumstances under which expedited resolution is available and how to request it

7. The member’s right to have benefits continue while awaiting the resolution of the appeal, how to request for continued benefits and circumstances where the member may be required to pay for the costs of services.

If you have questions or would like more information about Utilization Management denials or potential denials, please call us at 1-800-327-8613.

Miami-Dade County Judge Steven Leifman improves the lives of people living with mental illnessesGOVERNING Magazine recently announced Miami-Dade County Judge Steven as one of their eight Public Officials of the Year. Judge Leifman developed a national model for diverting individuals with mental illnesses out of jail and into treatment, after being deeply shaken in 1973 while personally observing the deplorable care given to patients at a state psychiatric hospital. This experience forever changed Judge Leifman’s perspective and his support for better treatment for people living with mental illnesses.

Miami-Dade County has the highest rate of mental illness in the nation; with one-fifth of arrests involving people with mental health conditions. Throughout his career, Judge Leifman implemented numerous initiatives to improve the care and treatment for these individuals. This included:

• Teaching police how to handle those in crisis

• Diversion of individuals with mental illnesses out of the criminal justice system into community treatment

• Conversion of a jail into a mental health-care facility

• Working with Jackson Memorial Hospital and Governor Rick Scott to integrate CMHP-style models of coordinated care.

Magellan Complete Care of Florida is proud to acknowledge Judge Leifman’s dedication to improve the lives of the members we serve.

How to contact the Utilization Management departmentAs a provider, you have the right to contact the Utilization Management department for information on Utilization Management processes and authorizations. For questions or concerns directed to the utilization management department, please call 1-800-327-8612 or 1-800-424-1694 TTY.

June 2014 | Caregiving8 Magellan Complete Care of Florida

Evaluating new and existing technologiesMagellan Complete Care is responsible for implementing coverage of new technologies with the direction of the Agency for Health Care Administration. The Health Services staff uses the Agency’s handbooks for standard Medicaid benefits and the contract for specialty plan expanded benefits as primary resources. The Agency for Health Care Administration will determine if medical and behavioral health care procedures, pharmaceuticals, devices and technologies are consistent with generally accepted professional medical standards and are not experimental or investigational.

How we identify and evaluate technology:To determine whether the medical and behavioral health care procedures, pharmaceuticals, devices and technologies are consistent with generally accepted medical standards, the following factors are considered:

1. Evidence-based clinical practice guidelines

2. Related credible scientific evidence

3. Effectiveness on improving the individual’s prognosis or health outcomes

4. Utilization trends

5. Coverage policy by other creditable insurance payer sources

6. Recommendations or assessments by clinical or technical experts on the subject or field.

Once the information is collected, a report with recommendations is submitted to the Deputy Secretary for Medicaid or designee for review who will make the final determination on whether it is consistent with generally accepted professional medical standards and not experimental or investigational.

In order for the service to be covered under the Florida Medicaid program, it must meet all other medical necessity criteria and be funded through the General Appropriations Act or Chapter 216, F.S.

8 Magellan Complete Care of FloridaC-N1106 (12/16) ©2016 Magellan Health, Inc.