A Personal Health Visit (PHV) is a detailed, comprehensive clinical visit
between a member and a clinician. During
the visit, the nurse practitioner will review the member?s medications with
them, discuss the importance of medication
adherence, do a physical exam, and provide a summary of every diagnosis related
to their entire medical history. As
a health insurance provider, AmeriHealth New Jersey does not directly provide
hands-on care to members; therefore,
AmeriHealth New Jersey contracts with third-party entities to perform this
service.
Background
The Centers for Medicare & Medicaid Services (CMS) requires all health plans
to conduct health risk assessments on
new Medicare Advantage members within 90 days of the member?s effective date.
AmeriHealth New Jersey performs
outreach to new members through the PHV program, asking them questions that
capture the health profile of the new
member.
In addition, CMS rates health plans on a number of quality metrics through a
measurement system called Star
Ratings. A health plan?s rating is based on the following five categories:
- staying healthy: screenings, tests, and vaccines;
- managing chronic (long-term) conditions;
- member experience with the health plan;
- member complaints, problems getting services, and
improvement in the health plan?s performance;
- health plan customer service experience.
As a result, health plans conduct PHVs to address the first category by
performing assessments, which can include
measuring body mass index (BMI), glycated hemoglobin (HbA1c) and microalbumin
biometric tests, and dexa scans
to address osteoporosis management in women. In addition, a PHV can indirectly
impact other measures, such as
screening measures and medication adherence. Please note that these gap
closures will be credited to the provider
office for AmeriHealth New Jersey-participating providers in a
pay-for-performance incentive program. PHVs will not
limit a provider?s bonus payments.
The PHV is not meant to replace the
member-physician relationship. In fact, it is meant to complement the
relationship. All results are faxed to the primary care physician (PCP) for
follow-up care, and members are called
3 ? 5 days after completing the PHV to assist them in scheduling an appointment
with their PCP, if needed. In
addition, the PHV does not replace the annual
wellness visit or ePASS® submissions, which physicians are still
encouraged to do and for which they will receive reimbursement.
If an issue is identified with the member, the vendor will notify
AmeriHealth New Jersey?s Case Management area for
follow-up services.
Benefits of a PHV
For members:
- a chance for members to discuss their health in
detail with a clinician;
- a convenient and accessible avenue for members
to receive health care services;
- an opportunity for Medicare Advantage members
to receive a $50 gift card for completing a PHV
(commercial members are ineligible for the
incentive at this time);
- ability for members to be transferred to
AmeriHealth New Jersey Customer Service at
1-888-YOUR-AH1 to assist in answering
benefit-related questions;
- members can receive timely referrals to Case
Management for health coaching or their PCP
and/or 911 in emergency situations.
For providers:
- provides PCPs with a snap-shot of the member?s
health through a fax summarizing what occurred
during the visit, allowing them to focus attention on
members with pressing needs;
- offers assistance in educating members on
preventive services and the importance of taking
control of one?s health;
- helps providers close Star Ratings gaps.
For more information on PHVs and Star Ratings, email us.