2024 Plan News
Feature Story – Shaun Ruskin Appointed Chief Operating Officer at VillageCareMAX
We are excited to announce the appointment of Shaun Ruskin as the new Chief Operating Officer (COO) for VillageCare and VillageCareMAX Managed Care Health Plans. With over 15 years of experience in healthcare leadership, Shaun brings a wealth of knowledge in strategic planning and operational excellence. His focus on improving operational efficiencies has consistently led to higher-quality care, reduced costs, and increased revenue.
Emma DeVito, President and CEO of VillageCare, expressed her enthusiasm: "Shaun's deep understanding of managed care and his strategic vision will be pivotal in shaping our future growth. His leadership will ensure that we continue to deliver exceptional care and maintain superior member satisfaction."
Shaun previously held key leadership roles at VillageCare and most recently served as Executive Vice President and Chief Strategy Officer at Centerlight Health Care. His contributions to the strategic turnaround at Centerlight, particularly in areas like Member Experience and Provider Relations, have been instrumental in strengthening the organization’s reputation and financial standing.
Shaun shared his excitement about returning to VillageCare: "I am honored to be back at VillageCare during such a dynamic time. I look forward to driving innovation, expanding our programs, and enhancing access to high-quality healthcare services for our members."
New Claims System - Cognizant Coming in 2025
As part of our ongoing commitment to enhancing your experience, we are excited to announce that a new and improved claims system, Cognizant, is on the horizon for 2025. This state-of-the-art platform is designed to streamline the claims submission process, making it more convenient and efficient for all our providers.
In the coming months, we will diligently prepare and test this system to ensure it meets your needs. Toward the end of the year, we will introduce the latest features of Cognizant and guide you through the registration process. We are confident that this upgrade will significantly improve how you manage claims with us.
In the meantime, please review and update any relevant information, such as service locations, billing addresses, language spoken, or W-9 details. Providing us with your most current information will help us ensure a smooth transition and seamless claims processing. Also, it is important to inform us if you are a PCP and wish to update or close the member panel. Please email your updated W-9 forms or any changes to your information to our Provider Relations team at [email protected].
Your cooperation and support are greatly appreciated as we work together to bring this new system online. We look forward to continuing our partnership and delivering the best possible service to you and your patients.
Mandatory Provider Trainings
Complete Your CAQH Profile
CAQH Re-attestation Every 120 days
As part of the VillageCareMAX Credentialing program, CAQH provider re-attestation is required every 120 days (180 days for Illinois providers) in the CAQH Provider Data Portal to ensure your credentialing data is maintained and accurate for health plan use.
To complete your re-attestation and more information on maintaining your credentialing data, please log on to the CAQH Provider Portal at https://proview.caqh.org/Login/Index?ReturnUrl=%2f.
Complete Your Mandatory Provider Training
Annual Provider Trainings 2024
As a crucial part of our commitment to delivering the highest standard of care, we want to reinforce the importance of completing the mandatory MOC (Model of Care) and CLSA (Culturally Sensitive Awareness) training.
If you still need to complete these essential trainings, we urge you to do so as soon as possible. Please click the link below to attest to your completion. Providers must fulfill these requirements to continue offering our members culturally sensitive and effective care. Please visit our website now to complete this training: https://www.villagecaremax.org/providers.
ACTION NEEDED: To ensure seamless delivery of these mandatory sessions, we kindly request providers to update your email. Please click this direct link for the Provider Demographic Change Form(e.g., changes or additions to address, phone, fax, email, panel, directory, Tax ID, etc.) or visit our website at https://www.villagecaremax.org/providers/provider-demographic-change-form.
Hedis Corner
Diabetes
According to the U.S. Centers for Disease Control and Prevention, diabetes rates may be reaching a plateau. However, among Hispanics and blacks, the incidence of diabetes continues to increase. These populations are also at increased risk from a Center for Medicare and Medicaid Service’s Health Equity outcomes standpoint. Continued focus on diabetes screening and prevention and ongoing patient education remain critical-particularly among these higher-risk populations. Even with the plateau, the rates remain a cause for concern, especially given the serious risks associated with diabetes, such as amputation, blindness, end-stage renal disease, and more. It is important to continue to talk to patients about lifestyle factors that affect their diabetes risk, such as diet and exercise. In addition, be sure to follow the HEDIS measures for diabetes care, which includes adult patients with Type 1 and Type 2 diabetes:
Hba1c testing: completed at least annually
HbA1c result > 9.0 = poor control
HbA1c result < 8.0 = good control
Dilated retinal eye exam: annually, unless prior negative exam; then every two years. Nephropathy screening test: eGFR and urine albumin creatinine ratio (UACR) at least annually (unless documented evidence of ESRD or on dialysis)
Blood Pressure Control: BP <140/90
Helpful hints:
• Counsel on healthy habits for managing diabetes and high blood pressure
• Encourage timely HbA1c testing.
• In progress notes, when documenting HbA1c value, include the full date the test was performed.
• Encourage medication adherence
• Review diabetic services needed at each office visit.
• Refer patients to an optometrist or ophthalmologist annually for a dilated or retinal eye exam.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.)
Please review our clinical practice guidelines at https://www.villagecaremax.org/clinical-practice-and-preventive-health-guidelines
Colorectal Cancer Screening
VillageCareMAX has partnered with Exact Sciences to send Cologuard® kits to our members in May 2024. Cologuard is a one-of-a-kind, noninvasive, and effective at-home colon cancer screening test that requires no prep and looks for abnormal DNA and blood in stool. It is for members who are at low risk for Colorectal cancer. Please educate and guide members if they reach out regarding receiving the Cologuard kit. You can find out more about how to use Cologuard here: https://www.cologuard.com/how-to-use-cologuard.
Falls Prevention
• Older adults are at increased risk of falling.
• More than 95% of hip fractures are due to falls.
• Falls and fall-related injuries increase the risk of nursing home placement.
• VillageCare offers important member benefits, such as Silver and Fit, which can help members improve bone and muscle strength, body coordination, balance, and flexibility. Please encourage your patients to join this program.
What is Silver & Fit?
• Silver & Fit is a fitness and wellness program for adults over 65 years old
• Members can receive access to no-cost or low-cost memberships to participating fitness centers (Planet Fitness, Blink, Crunch, Pure Barre, and others), exclusive exercise plans, and workout videos on demand.
• Additionally, anyone can join their daily workout classes on Facebook Live and YouTube, which are free and available to the public.
Pain and Older Adults
Pain is one of the most widely reported symptoms in older adults. 1 in 5 older adults report having pain, and it affects more people than diabetes, cancer, and heart disease combined. Chronic pain is the most common cause of long-term disability. Pain can lead to social isolation, depression, and falls.
What can you do to help your patients manage pain?
• Pain assessment should be done at each patient visit. It is easy to administer and requires little time.
• Help your patients set realistic pain treatment goals. These goals might not be a complete absence of pain but rather pain control to allow the patient to function.
• Assess the patient's pain regularly and frequently to facilitate appropriate treatment.
• Teach patients about pain medications and their adverse effects. Address issues of tolerance, dependence, and addiction.
• Educate patients on taking pain medications regularly, avoiding allowing pain to escalate, and using non-pharmacological strategies to manage pain, such as relaxation, deep breathing, meditation, massage, and the use of heat and cold.
• Refer to a pain management specialist when appropriate.
Health Outcomes Survey
Many of your patients received the 2024 Medicare Health Outcomes Survey (HOS) in the mail this summer. The interaction you have with your patients directly impacts HOS Star Measure Ratings. The Survey asks members about five topics: Physical Health, Mental Health, Physical Activity, Improving Bladder Control, and Reducing the Risk of Falling. Asking members critical questions about these topics during each visit, regardless of the primary reason for the visit, will increase the member's ability to recall discussing HOS-related questions with the provider. Posting educational material and checklists can help open and encourage dialogue between the patient and provider.
Key Quality Measures for 2024
As a provider of Managed Long-Term Care (MLTC) health plans, staying up to date with the New York State Department of Health's 2024 Quality Incentive Methodology is essential. These measures are designed to improve care delivery, member satisfaction, and health outcomes. You can ensure compliance and enhance service quality by aligning your efforts with these measures.
Here are some key quality measures for 2024:
• Members Who Did Not Have an Emergency Room Visit: Focus on reducing unnecessary emergency room visits through proactive care management and member education.
• Members Who Did Not Experience a Fall That Resulted in a Major Injury: Implement fall prevention strategies to ensure member safety and reduce injuries.
• Pain Intensity: Monitor and improve the management of pain intensity, ensuring members receive effective pain relief and support.
• Shortness of Breath Management: Assess and improve the percentage of members who report a reduction in shortness of breath, reflecting the effectiveness of interventions aimed at respiratory health.
• Urinary Continence Improvement: Measure the percentage of members reporting improvement in urinary continence, demonstrating effective management and support in addressing continence issues.
• Advanced Directive/Health Care Proxy Discussion: Evaluate the percentage of MLTC members who have discussed Advanced Directives or Health Care Proxies to ensure their preferences and wishes are documented and respected.
Focusing on these measures can significantly elevate the quality of care and improve member outcomes. By prioritizing these areas, you can optimize the health and satisfaction of those you serve.
Physician Network Pharmacy Corner
To optimal patient outcomes, medications being prescribed are included within our formulary. Not only does this allow patients to receive their medications promptly, but it mitigates unnecessary time being allocated to resolving these issues and allows more time for ensuring the health and safety of our members.
For a complete list of our formulary, which includes the drug name, quantity limit, and PA requirements, please visit our website at https://www.villagecaremax.org/map/2024-prescription-drug-coverage or speak with an agent at 1-800-469-6292.
Below is a list of common nonformulary medications being prescribed with our formulary alternative:
| Non-Formulary | VillageCare Max Formulary Alternatives |
| Icosapent Ethyl 1 Gram Capsule | Vascepa Oral Capsule 1 Gram (quantity limit 120 per 30 days) |
| Dapagliflozin 5/ 10 mg tablet | Farxiga Oral Tablet 5/10 mg tablet (quantity limit 30 per 30 days) |
| Basaglar 100 unit/ ml Kwikpen Insuline glargine solostar U100 Lantus solostar 100 unit/ mL | Semglee (insulin Glargine (1) YFGN) pen 100 unit/ml (3 mL) Semglee (Insulin Glargine (1) YFGN) solution 100 unit/ ml Toujeo max U-300 Solostar pen 300 unit/ ml (3 ml) Toujeo Solostar U-300 insulin pen 300 unit/ ml (1.5 ml) |
| Cyclosporine .05% eye emulsion 0.4 ml (60 vial) | Restasis multidose ophthalmic (eye) drops 0.05% Quantity limit (5.5 per 28 days) |
| Symbicort | budesonide-formoterol inhalation hfa aerosol inhaler 160-4.5 mcg/actuation, 80-4.5 mcg/actuation (quantity limit 30.6 per 30 days) |
Helpful Reminder
Change HealthCare has restored its service.
On March 25, 2024, Change Healthcare said its largest claims clearinghouses would return online over the weekend, more than a month after a cyberattack at the technology firm disrupted the healthcare sector. Electronic payments and electronic prescribing should be available now.
We do provide an alternate process for submitting claims. Providers can sign up with SDS’s Smart Data Stream portal to transmit claims files electronically. Providers can register using Payee ID # 26545.
https://portal.smartdatastream.us/quickclaim/servlet/quickclaim/template/ClearingHouse,Login.vm
In addition, there are additional ways that providers can submit claims by either using another clearinghouse such as Ability or by submitting paper medical claims submission through the addresses below:
Ability: https://providercloud.inovalon.com/Auth/
Paper Claims Submission:
ILS – VillageCareMAX
P.O. Box 21516
Eagan, MN 55121
For any concerns about claims payment, please contact our Provider Services Call Center at 855-769-2500. If you have unresolved questions, please email the VCM Provider Relations team at [email protected].
Behavioral Health (BH) Vendor – Carelon Contact information
As a reminder, effective January 1, 2023, VillageCareMAX Behavioral Health benefits are administered by Carelon Behavioral Health (formerly known as Beacon Health Options) for MAP and DSNP programs. Important Information for Carelon Behavioral Health:
• Carelon Phone Number: (800) 397-1630
• Between 8 a.m. and 8 p.m. ET, Monday through Friday.
• Carelon Contact Link: www.carelonbehavioralhealth.com/contact-us
• Join the Carelon Provider Network: https://www.carelonbehavioralhealth.com/providers/join-our-network
Service Centers Across New York: Here to Assist Your Patients
We are pleased to remind you that VillageCareMAX has established several service centers throughout New York City dedicated to supporting your patients with any questions or assistance they may need. Our knowledgeable staff at these locations are always ready to provide guidance and ensure your patients receive the help they require.
Please direct your patients to visit any of the following service centers for assistance:
Manhattan Service Center:
Location: 112 Charles Street, New York, NY
Phone: 800-469-6292
Brooklyn Service Center:
Location: 6120 7th Ave, Brooklyn, NY 11220
Phone: 718-517-2650
Bronx Service Center:
Location: 798 Southern Blvd, Bronx, NY 10455
Phone: 718-517-2700
Queens Service Center:
Location: 41-80 Main Street, Flushing, NY 11355
Phone: 718-517-2600
We encourage you to direct your patients to visit any of these locations for support, and we are always here to assist them in any way we can.