Insurance Updates Effective January 1, 2023
2023 brings forth continued positive changes for doctors of chiropractic practicing in New York. Across the state certain health plans have increased fee schedules and enhanced coverage. In addition, a few third-party administrators have been eliminated, and unreasonable utilization review has been discontinued. Reasonable reimbursement and the elimination of administrative burdens affords us more time to assist our patients in achieving their goals. With significant involvement from our members, the NYSCA continues our drive to parity and fairness in reimbursement and administrative practices.
Unfortunately, some insurance carriers and/or third party administers were delayed in (or refrained from) providing notice to their contracted providers. Under certain circumstances, health plans subject to the laws of New York are required to give 90 days written notice before implementing a contract change that could have an adverse impact on your aggregate level of payment. This allows treating doctors to evaluate the positive and negative attributes of the change, and make a determination as to whether or not they wish to participate with that plan.
The NYSCA Insurance Committee (The NIC) would like to keep you informed by providing the following summary of changes which became effective January 1, 2023. Please contact the NYSCA is you have additional examples which we can share with our members.
Aetna
Aetna has discontinued the use of NIA/Magellan for precertification of chiropractic services for Aetna's fully insured population. Many of you received notice of an American Specialties (ASH) Aetna Chiropractic Webinar. Members of the NYSCA Insurance Committee (The NIC) attended the webinar and also confirmed with ASH that the new Aetna program does not include New York (the changes were limited to Georgia, Washington and Oregon). For services rendered on or after January 1, 2023, submit your claims and inquiries directly to Aetna as noted on the back of your patient's insurance identification card.
CDPHP
This is an excellent example of how health plans are recognizing the value of services provided by doctors of chiropractic in New York. As many of you are aware, Medicare and most Medicare Advantage programs only cover one (but vital) portion of the chiropractic visit: Spinal CMT. The lack of coverage for medically necessary services (e.g., examinations and physical medicine) places an undue financial burden on patients, which may impact their ability to seek care in our offices.
CDPHP just announced the following:
“In addition to the standard Medicare-covered chiropractic services, medically necessary chiropractic services will be covered when performed by a licensed Doctor of Chiropractic – including assessment, manipulations and modalities.”
We anticipate that other Medicare based programs adopt this practice. Perhaps this is why CDPHP achieved a 5 Star Overall Rating from Medicare this year!
Healthfirst
ASH posted notice on ASHLink in September to announce the addition of Healthfirst’s Medicare Advantage PPO membership. This notice states:
“HealthFirst will begin offering a chiropractic subluxation benefit through ASH IPA-NY effective January 1st, 2023. This new benefit will be available to their Medicare Advantage PPO membership. Please review the Healthfirst Client Summary and Fee Schedules for more information on how this plan will be administered.”
Note the Healthfirst Client Summaries on ASHLink have been updated to incorporate Healthfirst’s Medicare Advantage enrollees. Also recall that ASH allows providers to elect not to participate on a client (e.g., Healthfirst), not plan type (e.g., Medicare Advantage program) basis.
The NIC has verified with American Specialties that coverage for Healthfirst Medicare Advantage enrollees includes medically necessary examinations, physical medicine, and other services as outlined in the Healthfirst Client Summary and Fee Schedules. By working with American Specialties, Healthfirst has added this important ryder, offering enhanced benefits to chiropractic patients in New York.
MVP
MVP provided more than adequate notice as they discontinued their relationship with Landmark/eviCore for chiropractic services and developed their own chiropractic network. MVP's revised chiropractic benefit program which went into effect January 1, 2023. The new program allows doctors of chiropractic to order lab tests and high tech imaging, bill for non-covered services and implemented a competitive fee schedule. Prior authorization may be required for certain services, as they are with other specialists.
Some NYSCA members contacted the NIC, noting that MVP was reimbursing more than the amount billed. NYSCA reached out to MVP, who noted:
there is no contract language that speaks to “lesser of” billed charges or the flat rate, MVP is paying in accordance with the contract by paying $60. The $60 is not an overpayment, rather a contractual rate that MVP is required to pay for covered services.
Refreshing. The NYSCA would also like to acknowledge MVP's sponsorship of District 15's holiday gathering.
Important reminders relative to Medicare Advantage enrollees:
Do not forget to add the Active Treatment (AT) modifier to your CMT code when billing for active treatment to your Medicare Advantage patients to clearly indicate that treatment is not maintenance care. Failure to do so may result in a claim denial (as with your Medicare patients).
Providers cannot bill for non-covered services unless they request prior authorization and the enrollee receives a written denial from MVP. Recall that the rules that govern Medicare Advantage enrollees differ from Medicare and other types of insurance, and are subject to ongoing updates (as recent as 2 weeks ago). For instance, ABNs cannot be used for Medicare Advantage enrollees. Records for Medicare Advantage enrollees must be retained for 10 years.
Orange Ulster School District
Orange Ulster School District's (OUSD) chiropractic program is no longer administered via Optum / Unitedhealthgroup. The NIC has reached out to Orange Ulster School Districts' Health Plan executive director as well as their new claims processor Trustmark Health Benefits to encourage the dissemination of plan changes to providers who render care to their enrollees.
Please note that OUSD members received a new insurance ID card with a new ID number effective January 1, 2023. You must utilize the new ID number in obtain eligibility and benefits information. Trustmark is unable to locate benefits via the old ID, and can be reached at 1-888-604-9397. Benefits appear to be managed via the local Blue Cross Blue Shield office, not American Specialties (as verified by ASH). As always, verify eligibility and the parameters of coverage through the health plan and/or their delegated third party administrator.
Oscar
Oscar Health Insurance is now requiring chiropractors to use subluxation as the primary diagnosis, and incorporate the AT modifier on CMT codes (e.g., 98940).
The use of the AT modifier is a growing requirement for health plans, and is used to distinguish to between active treatment vs maintenance care which is typically not a covered benefit.
Wellcare
Wellcare began offering chiropractic benefits through a new relationship with ASH. The new benefit will be available to Wellcare's Medicare Advantage HMO and PPO membership. Notice of the partnership was posted on Wellcare's website via a memo dated January 26, 2023. ASH posted notice on ASHLink on December 22 entitled 'additional updates effective January 1st'. ASH also updated the applicable Client Summaries to include Wellcare, and has provided a specific fee schedule.
The NIC has also verified with American Specialties that coverage for Wellcare’s Medicare Advantage enrollees includes medically necessary examinations, physical medicine, and other services as outlined in the Wellcare Client Summary and Fee Schedules posted on ASHLink. Another great step forward for Medicare Advantage enrollees in New York!
ASH
If you are a participating provider with ASH, the NIC encourages you to review important notifications by logging in to ASHLink and checking your Inbox. In addition, you should select Resources for updates to Client Summaries, Notifications, and other important information.
ASH also provided notice relative to E&M services for ASH Tier 6 practitioners. For those of you who reported a problem with the Notification link, you should be able to access the information from your ASHLink Inbox:
Effective January 1, 2023, changes were made to the number of Evaluation and Management (E&M) services allowed under the CPS tiers. The following Medically Necessary services Examinations are eligible without the submission of an MNR form for Tier 6 practitioners. The number and type of other services covered under the CPS remain unchanged.
• (1) one New Patient Office Visit/Examination and up to (3) three of the following:
◦ Established Patient Office Visit/Examination
◦ Online digital E&M service
◦ Telephone E&M service
Or
• Up to (4) four Established Patient Office Visits/Examinations; (4) four online digital E&M services; (4) four telephone E&M services
The NIC is also working to resolve issues relative to Cigna (lack of claims acknowledgement and processing), Fidelis (appropriate coverage for spinal conditions) and Highmark BCBS (multiple administrative issues). Further information will be forthcoming within the next week relative to these three health plans.
As always, the NYSCA thanks you for your continued dedication to your patients, our profession and this organization. By working together we will continue to transition New York into The BEST PLACE TO PRACTICE.
TOGETHER WE ARE NYSCA.
