Provider News & Updates – June 2023 - Samaritan Health Plans

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End of Public Health Emergency Changes Medical Benefits

The COVID-19 public health emergency officially ended on May 11, 2023. As a result, changes apply to some medical and pharmacy out-of-pocket costs for COVID-19-related services provided to Samaritan Advantage Health Plans, Samaritan Choice Plans and Samaritan Employer Group Plans members.

Samaritan Advantage Health Plans benefit changes include the following:

FDA-approved COVID-19 vaccines have a zero-dollar ($0) copay when prescribed by a health care professional and filled at a network pharmacy.
Anti-viral prescriptions for Paxlovid (nirmatrelvir/ritonavir) and Lagevrio (molnupiravir) have a Tier 4 copay when prescribed by a health care professional and filled at a network pharmacy.
COVID-19 diagnostic tests performed by a physician or laboratory are free and have no cost share.
At home over-the-counter COVID-19 tests can be purchased by the member and reimbursed through the over-the-counter benefit.

Samaritan Choice Plans and Samaritan Employer Group Plans benefit changes include the following:

FDA-approved COVID-19 vaccines have a zero-dollar ($0) copay when prescribed by a health care professional and filled at a network pharmacy.
Anti-viral prescriptions for Paxlovid (nirmatrelvir/ritonavir) and Lagevrio (molnupiravir) have a Tier 3 copay when prescribed by a health care professional and filled at a network pharmacy.
COVID-19 diagnostic tests performed by a provider or laboratory are subject to plan deductible, copay and coinsurance.
At-home over-the-counter COVID-19 tests are not covered.

Contracted telehealth services continue to have a zero-dollar ($0) copay for all Samaritan Advantage Health Plans, Samaritan Choice Plans and Employer Group Plans members for the remainder of 2023. Non-contracted telehealth services will apply to members’ out-of-network plan benefits.

Care Management Dedicated to Improving Outcomes for Members With Special Needs

Dual-Eligible Special Needs Plan, also known as DSNP, is a specialized Medicare Advantage plan that provides health care benefits for members who have both Medicare and Medicaid coverage and are dual-enrolled in a Samaritan Advantage Health Plan and InterCommunity Health Network Coordinated Care Organization.

DSNP members have an initial health risk assessment within their first 90 days of enrollment and within 365 days from their last HRA thereafter. The HRA is a series of questions designed to best identify a member’s state of health, risk for exacerbation of acute and chronic conditions, functional decline and social issues likely to impact the member’s ability to achieve personal health and well-being goals.

Each DSNP member will have an individualized care plan, also known as ICP, completed upon initial enrollment and updated at least quarterly or with a change in health care needs. The purpose of the ICP is to identify gaps in care, at-risk areas, knowledge deficits and self-management issues. The goal is to develop individualized, member-centric goals with correlating health care professional interventions. The ICP meeting with the member will be completed by a Samaritan Health Plans case manager using the member’s medical history, health care, cultural and linguistic preferences, pharmacy utilization and input from all active members of the Interdisciplinary Care Team.

The Interdisciplinary Care Team, also known as ICT, is a group of health care professionals from diverse fields who consistently work toward a common goal for improved member care. The core team consists of the member or member’s representative, the member’s primary care provider or PCP designee and the SHP case manager. The case manager acts as the single point of contact for the member, documents the ICP meeting in the member’s record and updates the care plan when necessary.

The provider’s role is to be a collaborative and participatory member of the ICT by communicating with the SHP case manager, other ICT members and the member’s caregivers or representatives. Providers are expected to complete the Special Needs Plan Model of Care training upon onboarding and again on an annual basis.

To speak with a case manager, please call SHP’s Care Coordination team at 541-768-4877. Direct referrals can be faxed to 541-768-9768 or emailed to [email protected].

Clinical Practice Guidelines Updated & Adopted for Hypertension

Samaritan Health Plans develops and adopts evidence-based Clinical Practice Guidelines, also known as CPGs. The CPGs are meant to assist providers in making decisions about appropriate health care for specific clinical circumstances. They are also intended to improve the quality and consistency of care provided to members. Each CPG developed and adopted by SHP is endorsed by a physician champion and adopted by SHP’s Quality Management Council.

The QMC recently adopted the Hypertension Guideline. This guideline was reviewed per SHP policy and no changes were made to the references.

To review all CPGs, please visit the Care Management webpage and click the down arrow to view the Clinical Guidelines section. There you’ll find medical, behavioral health and dental health guidelines.

Podiatry Services Subject to Outpatient Hospital Cost Shares

Samaritan Advantage Health Plans distinguishes podiatry services separately from other specialist services and applies specific podiatry cost shares to the member. Bill type and place of service will affect member cost shares significantly. Podiatry and other services performed in an outpatient hospital treatment room will be processed and reimbursed according to the outpatient hospital benefit for the SAHP plan year. Cost shares for outpatient hospital services have increased from 2022 to 2023. Of note is the change from a 15% coinsurance to a $300 copay on Samaritan Advantage Health Plans’ Premier Plus plan. Samaritan Health Plans asks providers and their staff to be aware of this change while informing patients of their financial responsibility associated with receiving podiatry services at an outpatient hospital.

Cost shares for podiatry services performed in an office setting are significantly lower. The tables below detail the cost share amounts for both outpatient hospital services (including podiatry) and in-office podiatry services.

Outpatient Hospital Cost Shares for Samaritan Advantage Health Plans	2022	2023
Conventional Plan	$200 copay	$325 copay
Premier Plan	$250 copay	$350 copay
Premier Plus Plan	15% coinsurance	$300 copay
Special Needs Plan	20% coinsurance	20% coinsurance

In-office Podiatry Cost Shares for Samaritan Advantage Health Plans	2022	2023
Conventional Plan	$20 copay	$20 copay
Premier Plan	$35 copay	$35 copay
Premier Plus Plan	$35 copay	$35 copay
Special Needs Plan	20% coinsurance	20% coinsurance

Samaritan Health Plans appreciates the care provided to each of our Samaritan Advantage members. For questions or concerns regarding cost shares for specific services or service locations, please contact a customer service representative at 541-768-5207 or toll free at 888-435-2396.

Medical Coverage Policies Reviewed & Updated for 2023

In the absence of primary clinical criteria, Samaritan Health Plans develops medical coverage policies to communicate decisions about coverage and benefits for various medical services. Medical coverage policies are reviewed annually. In 2023, SHP reviewed or updated the following medical coverage policies:

Evaluation of New and Existing Technologies.
Computer-Assisted Surgical Navigational Procedure.
Wireless Gastrointestinal Monitoring System (aka “SmartPill”).
Advanced Care Planning.
Psychiatric Sub-Acute Admission.
Gender Dysphoria Medical Necessity Criteria.
Genetic Testing.
Proprietary Laboratory Analyses.

To read SHP’s medical coverage policies, please visit the Care Management webpage and click the down arrow to view the Medical Coverage Policies section.

Check These Important Reminders & Notices

Quarterly Provider Webinar to Be Held in Early June

Register for one of the Samaritan Health Plans quarterly provider webinars to receive provider-related updates and information from SHP and IHN-CCO. If you would like to attend but did not receive an invitation, please email [email protected] for an invitation to the current session. To ensure receipt of future webinar invitations, please sign up for Provider News.

When: June 7, 1 to 2 p.m., or June 8, 10 to 11 a.m.
Where: Virtual Teams meeting

Credentialing & Re-Credentialing Application Mandate

As of April 23, provider credentialing and re-credentialing must be submitted using Oregon Health Authority’s 2021 version applications. All previous iterations of these applications will no longer be accepted. Providers can access the mandated 2021 application forms by visiting the Advisory Committee on Physician Credentialing Information portion of OHA’s website at Oregon.gov.