To ensure optimal health and wellness for every MetroPlus member assigned to our department through the provision of comprehensive care coordination, adherence engagement, health education and supportive services in a caring, nonjudgmental and empowering manner.
CRITERIA FOR BEING AN HIV SPECIALIST PCP
In order to accept the assignment of people enrolled in our Partnership In Care Special Needs Plan, a provider must be credentialed. The provider must be experienced in the primary care of people with HIV and meet the criteria of one of the following recognized bodies: the HIV Medicine Association, specialist status as accorded by the American Academy of HIV Medicine or Advanced AIDS Credited Registered Nurse Credential given by the HIV/AIDS Nursing certification Board.
The easiest way to meet the requirement is to take and pass the certification exam by the American Academy of HIV Medicine. The certification is for a 3 year period beginning January of the following year from the testing date. To qualify, the provider must be caring for at least 20 HIV+ patients and complete a minimum of 30 credits of HIV-related Category 1 CME/CEU/CE within the 24 months preceding the date of application. The open book exam has a 125 multiple choice questions relevant to the current state of care of HIV and is taken online. Registration for the 2016 wave 2 test window (November 14th – December 1st) opened as of September 1st and closes November 4th. There is a fee of $370 for non- members but it is reduced to $270 for members of the Academy.
The HIV Medicine association definition of an HIV specialist physician requires 25 ongoing patients cared for in the previous 36 months, 40 hours of HIV related CME (with at least 10 per year) in the previous 36 months and either board certification or 5 years experience in HIV primary care. Newly graduating ID fellows are considered qualified for 36 months after completion of their program. These criteria are a little more stringent and requires more documentation to prove.
Nurse practitioners can be certified through the Nursing Board above or through the American Academy of HIV Medicine. Physician assistants who provide HIV primary care are not able to be credentialed as an HIV Specialist PCP for MetroPlus but are encouraged to take the American Academy of HIV Medicine exam not only for the credential it provides but also for the learning experience of the exam itself.
BEHAVIORAL HEALTH REFERRALS FOR METROPLUS MEMBERS
MetroPlus Health Plan has contracted with Beacon Health Strategies to provide utilization management for members with psychiatric and substance abuse needs. This includes screening of all psychiatric hospital, substance abuse detoxification and substance abuse rehabilitation admissions. Beacon case managers help our members access mental health and substance abuse services.
Any provider can contact Beacon directly to initiate a referral by sending an email to MPBHReferral@beaconhs.com
and providing the following information (if known): primary Issue (medical, behavioral health, co-morbidity); diagnosis (medical and behavioral health); all current medications and doses; any dates of medical or psychiatric hospitalizations and reason; present behavioral health symptoms; whether the member is pregnant or recently gave birth; current living situation (homeless, shelter, lives on own, etc); and family, legal, and/or social history. Beacon will reach out to the patient and offer to assist with whatever behavioral health referral may be needed.
VERIFICATION OF HIV STATUS REQUIREMENT
As per NYS regulation, MetroPlus must verify the HIV status of all people enrolled in the HIV Special Needs Plan within 90 days. If we do not, we have to disenroll them. We can use a variety of medical evidence including confirmed HIV antibody, detectable HIV viral load and results of HIV genotype testing. We will also accept progress notes that document that the individual is on antiretroviral therapy, is known to the provider as being HIV+ and has an undetectable viral load.
Our staff have to reach out to staff at our participating providers’ offices and request this information. Please cooperate with these requests. According to HIPAA regulations, the patient’s informed consent is not needed when the insurer is collecting personal health information for business operations and quality purposes.
It is best practice to always confirm HIV status by drawing an HIV antibody when a new patient is seen who presents with a history of being positive, undetectable and on treatment.
ZEPATIER IS NOW THE METROPLUS PREFERRED DRUG FOR HEPATITIS C
Zepatier has replaced Harvoni as the preferred treatment for Hepatitis C genotypes 1 or 4. Harvoni is now non-formulary and will only be authorized for certain situations, such as prior failure or intolerance to formulary agents. The other formulary agents are Sovaldi and ribavirin. Technivie, Viekera Pak and Daklinza are non-formulary, but can be obtained under certain circumstances. Epclusa is not yet available.
Generic Epzicom (abacavir-lamivudine combination tablet) is now available. MetroPlus has about 300 members who currently receive this medication. Going forward, this medication will be switched to the generic form – please forewarn your patients. Many patients are leery of generic drugs and will require preemptive education to allay potential fear. A prior authorization will soon be required for the brand name.
IT’S FLU SHOT SEASON!
September marks the beginning of the annual effort to prevent Influenza by given a flu shot. Influenza vaccination is recommended for all people with HIV infection, regardless of CD4 count or viral load. Flu shots are a covered MetroPlus benefit. The rate of vaccination of HIV+ people enrolled in MetroPlus is higher than the general population, so keep up the good work.
Influenza vaccination is also a good reminder to check the status of pneumococcal vaccination. Pneumococcal pneumonia is 8 times more likely in an unvaccinated HIV+ person than someone without HIV. The 23-valent polysaccharide pneumococcal vaccine is recommended to be given every 5 years to someone with HIV infection. The 13-valent conjugate pneumococcal vaccine is also recommended to be given once to someone with HIV infection, either 8 weeks before the polysaccharide vaccine or 12 months after it. Pneumococcal vaccination is also a covered MetroPlus benefits.