HEDIS measures, related to statin utilization, focus on members with diabetes, as statins are an important component for primary prevention in atherosclerotic cardiovascular disease (ASCVD) in this patient population and in members with ASCVD as prevention against secondary cardiovascular events.

Statin initiation is a key component of these two measures and equally important is the adherence to the prescribed statin medication. The recommendation for diabetics to utilize statins applies to all patients with diabetes, regardless of LDL levels.

Measure Description: This measure captures the percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria. Two rates are collected in this measure:

As a regulation of Health Care Reform (HCR), statins categorized as low-to-moderate intensity are covered with no member cost-share. Generally, these doses are also well tolerated and as such should not be a barrier to treatment initiation.

Measurement Description: This measure captures the percentage of males 21–75 years of age and females 40–75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. The following rates are reported:

The diagnosis of obesity has a strong-hold on our country. According to the CDC, the prevalence of obesity in the United States has increased from 30.5% (the prevalence in 1999-2000) to 41.9% for the timeframe of 2017-March 2020. In the same time frame, the prevalence of severe obesity, defined as a BMI ≥40, has increased from 4.7% to 9.2%. It is clear, that focused attention to the management and treatment of this chronic disease is necessary to limit the progression of this disease and obesity-related conditions.

The current treatment of obesity is heavily focused on medications that are traditionally utilized in the management of uncontrolled type-2 diabetes. GLP-1 agonists, glucagon-like peptide-1, helps limit appetite by signaling to our bodies that we feel full and prompts our stomachs to empty more slowly.

Emerging evidence indicates success when using these medications as treatments for obesity; however, this success is not without potential complications and risk. Additionally, when these medications are stopped, many patients experience rapid weight gain. The impact of long-term utilization of these medications for weight-loss is also still unknown. Side effects with these medications can be severe in many patients, even at the recommended low starting doses. Commonly reported side effects include, nausea/vomiting, diarrhea or constipation, abdominal pain and distention; side effects alone often result in discontinuation for many patients. There is also risk for acute pancreatitis when using these medications. While the advent of new medications is both promising and exciting, the utilization of medications, particularly the GLP-1 agonist medications, in the treatment of obesity has reached a fever pitch that has now put the treatment of patients with Type 2 diabetes in jeopardy, as significant shortages of these medications is ongoing.

Successful weight-loss programs are multi-faceted and require frequent follow-up to ensure patients are meeting outcomes in a variety of areas including behavioral and diet modifications, goal setting, and goal management, and in appropriate settings, medication management. In an effort to maintain supply for those whose diagnosis depends on these medications, MAHP, in most cases, does not cover these medications unless associated with a diabetic diagnosis.

The Provider Portals contain formulary links and other useful materials, such as Prescription Medication PA request forms. The Optum Rx Premium Formulary for MAHP and Health Choices can be found here, and the formulary for Live360 can be found here.

MAHP requires authorization on select genetic/molecular testing procedures. Genetic/molecular testing performed without prior authorization may not be reimbursed by MAHP. Ordering providers should coordinate with the rendering lab/facility to ensure authorization is requested prior to rendering these services. Authorizations will be specific to the CPT code(s) requested. If the test is part of a panel, all CPT codes will be reviewed for appropriateness and can be initiated on the provider portal. If the service performed is different than what was initially authorized, the rendering facility must contact MAHP to make revisions and authorization prior to claim submission.

Please remember to always check authorization requirements along with member benefits and eligibility beforehand via the provider portal. For MAHP and Live360 members, access the portal here. For Health Choices members, click here.

Provider Verification Required: The Consolidated Appropriations Act (CAA) requires provider directory information to be validated every 90 days.

CAA was signed into law on December 27, 2020. Effective January 1, 2022, the CAA mandates new requirements for maintaining and validating information included in provider directories. CAA requires that all health insurers, including MAHP/Health Choices/Live360, regularly maintain an online provider directory to members and that providers validate their information every 90 days. The directories are made available to participants, and enrollees. The provider directory must contain the following information about each provider:

Each quarter, we will email a site questionnaire to the credentialing contact at the office. The questionnaire must be reviewed, with corrections noted and returned by the deadline stated in the corresponding email. Failure to respond in a timely manner will result in providers being removed from the provider directory. Providers will not be removed from the network at that time. Providers can be added back to the directory upon completion of the site questionnaire.

If a provider’s office misses two consecutive quarterly site questionnaires, the office may receive a notice of termination for failure to comply with the CAA provider directory validation provisions.

Please watch for emails with ***Action Required***Site Questionnaire as the subject.

Questions: Please email MAHPCredentialing@mahealthcare.com.

Updated 2023 Provider Reference Guide Now Available

The Provider Reference Guide has been prepared as a daily reference tool for participating practitioners and their office staff. Access this updated document here. The Reference Guide is password protected. To access the file, please type the following password: provider

Please review the following sections as significant changes were made to:

Medical Associates Health Plans participating providers, click here.

Health Choices participating providers, click here.

Live360 Health Plan participating providers, click here.

If you have not yet signed up for this time-saving service, you will need your federal tax ID number to create an account. Any questions, please contact Member Services mahpmemberservices@mahealthcare.com.

Information related to MAHP's quality improvement plan, case management services, disease management services, member rights, communications, appeals process, after-hours assistance, accreditation/awards, and privacy/confidentiality may be viewed at www.mahealthplans.com. Persons without access to the internet may request paper copies by contacting MAHP at 1-800-747-8900 or 563-556-8070. Please ask to speak with a member of the QI team for assistance.