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In this bulletin, we’ll share details of some recent pilot projects, an update about our virtual primary care partnership with Firefly Health, recent benefits updates for our Members that can help your patients, important coding updates, and some recent blog posts.
Twig project spurs glucose testing for Members with Type 2 diabetes
Community Health Options partnered with Twig Health to help decrease the risks that come with high blood sugar levels—heart or kidney disease, blindness, nerve damage or stroke, among other things—by ensuring appropriate use of A1C blood tests, which measure blood sugar levels.
About 10% of Maine’s population are living with diabetes and more than 35% have prediabetes, with more than 6,800 Mainers being diagnosed with Type 2 diabetes every year, according to the American Diabetes Association.
The project is a part of Community Health Options’ ongoing commitment to prevent diabetes and its complications by working to close gaps in healthcare for its Members.
In a short six-week project at the end of 2024, using Twig’s innovative combination of text, AI and licensed nurses, 49% of 146 Members who were due for A1C testing agreed to participate in the program, and half of those immediately scheduled their tests. In this first foray into text messaging, Twig found that 62% of Community Health Options Members preferred texting over other forms of contact.
The Twig project follows several efforts to address diabetes. They include:
- A first-ever direct collaboration with a provider: In 2024, Community Health Options teamed up with Martin’s Point Health to help ensure Members with diabetes who are their patients have the resources to lower their A1c levels. Martin’s Point providers partnered directly with Community Health Options’ care managers to address any barriers to care. At the end of the outreach, 50% of contacted Members reached an A1C level below 8.
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A project with Blue Circle Health launched this year to provide free education and support for Members 18 and over who have Type 1 diabetes. This program is meant to close the knowledge gap many adults face when it comes to knowing what kind of care they need, diet they should follow, how to manage glucose levels and other issues.
- The 2025 Community Health Options Wellness Grants, which will offer five $10,000 grants to Maine nonprofits that foster good nutrition, physical activity and healthy habits that reduce the risk of developing Type 2 diabetes and associated complications. Organizations can begin applying as early as Monday, March 10.
Highlights of key benefits we offer Members
The following benefits are available to our Members to help you serve your patients:
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GLP-1 for Weight Loss: To help employers who want to offer GLP-1 drugs to their employees, we have introduced a unique formulary (Rx3) that includes GLP-1 products approved for weight loss (Wegovy, Zepbound and Saxenda) in Tier 3, alongside other GLP-1s for diabetes control on select plans. The Rx3 formulary includes other weight loss medications as well and has a different cost-share schedule compared to Rx1. That includes higher cost-sharing for Members for Tier 3, 4, and 5 medications.
Express Scripts helps to manage access and adherence to the medications with its Weight Value Program. Members must have a BMI over 32, or between 27 and 32 with two documented co-morbidities.
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Chronic Illness Support Program(CISP): We have now expanded this program to Large Group HSA plans. To comply with IRS rules for high-deductible health plans, the benefits are slightly different, and help reduce financial barriers to care for those Members with coronary artery disease, high blood pressure, diabetes, COPD and asthma.
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Lower co-pays for urgent care site of service: Members on all Large Group non-HSA plans will pay lower copays by using specified urgent care centers. Members pay between $25 and $40 depending on their plan to encourage them to use urgent care centers instead of emergency departments, ultimately reducing the cost of their care. Members can also find the information in their portal and through site-of-service designations in the provider directory.
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Site of Service: Community Health Options Members on all Individual, Small Group and most Large Group non-HSA plans have X-rays at specified locations with a $75 copay, while labs have a $25 copay at specified locations. HSA Members pay a copay or coinsurance after they’ve met their deductible. Members can find the list in their portal or in the provider director.
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Pediatric and adult vision copays: All Individual, Small Group and most Large Group non-HSA plans include pediatric vision exams with a primary copay. Most Large Group and Individual/Small Group national silver, gold and platinum plans, also include adult vision exams with a copay and no deductible. (HSA has the copay after deductibles are met).
Firefly users praise ease of access to providers
Community Health Options Members using Firefly Health as a virtual primary care provider have experienced easy access to the care they need and quick appointments—usually within three days—along with easy referrals to specialists. Almost 95% of Members said they were satisfied with the service in post-visit surveys, especially citing seamless referrals to a range of local specialists, including behavioral health professionals.
For example, a Member who survived breast cancer needed primary care and wanted to make some lifestyle improvements. She had weekly check-ins with a health guide that helped her reduce stress and maintain a positive outlook. When she started displaying concerning symptoms, her team referred her to a local provider for follow-up, and her specialist quickly detected and removed a potentially concerning pathogen.
“It’s so easy to use! I can be in touch with my medical team via the chat portal. I love it!,” said one Member. Another was “really happy with the speed of replies, speed of appointments and access to care.”
Members using Firefly get a primary care team that includes a medical doctor, nurse practitioner, behavioral health specialist and health guide. The team refers Members to local providers when they need to see someone in person. All Members 18 and over can choose Firefly Health, giving Members an option for primary care and alleviating some strain on primary care providers who are unable to take on any more patients.
New American Medical Association Telemedicine Codes
The American Medical Association (AMA) recently released new Telemedicine/Telehealth CPT codes effective 1/1/2025. This code set includes 98000-98016. These codes are meant to replace the standard E/M CPT code/modifier combination that is standard billing for these types of services. CMS has opted not to reimburse these codes with the exception of 98016.
In accordance with our Telehealth/Telemedicine Services Policy found here on our website, Community Health Options will be following CMS and excluding these codes as reimbursable for Telemedicine and Telehealth services. Please refer to the policy on our website for acceptable billing practices.
Sit-to-stand system now covered with Prior Approval
Combination sit-to-stand frame/table systems (HCPCS Code E0637) is covered with a Prior Approval, effective Jan. 1, 2025. The equipment is now covered in any size, including pediatric, with a seat lift feature, and with or without wheels.
Additional code changes, effective April 1, 2025:
- 93356 moving to Experimental and Investigational
- 69990 moving to No Prior Approval Required
- 81515 and 87798 moving to Prior Approval Required
Medical Benefit Management Updates
Newly Added Medications Requiring Prior Approval, Effective January 1, 2025
Medications subject to voluntary Site of Care transition are denoted with an asterisk (*).
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