CurrentHighmark PennsylvaniaPolicy N/A

Congestive Heart Failure (CHF) Management Program (Vida Health)

Defines the Highmark Pennsylvania CHF management program including services offered, eligibility/inclusion and exclusion criteria, enrollment/referral pathways, and program features. Governs access to a digital and coaching-based CHF care management solution for eligible Highmark members.

Policy Summary

PayerHighmark Pennsylvania

PolicyCongestive Heart Failure (CHF) Management Program (Vida Health)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument patient age (≥18), CHF diagnosis, and plan type (Highmark ACA, Medicare Advantage, or Commercial) and confirm absence of any listed exclusion conditions prior to enrollment.

POLICY UPDATE CHANGES

No material changes to clinical coverage or eligibility criteria.

15%Reduction in hospital admissions

8% (up to)Reduction in ED visits

1 in 2Improved physician engagement

No cost for most membersMember cost sharing

Coverage Summary

This policy defines the Highmark Pennsylvania CHF Management program, a digital and coaching-based congestive heart failure care management solution. The program leverages 1:1 coaching, digital tools, clinician collaboration, and education resources (including digital scales and blood pressure monitors) to improve outcomes, reduce hospitalizations and ED visits, and increase adherence and physician engagement. It governs eligibility (inclusion and exclusion criteria), enrollment and referral pathways, and program features for eligible Highmark members.

Medical-Necessity Criteria

Inclusion Criteria

Covered when ALL of the following are met:

Age: Patient is ≥ 18 years old
Diagnosis: Patient has a diagnosis of congestive heart failure (CHF)
Plan Enrollment: Patient is enrolled in a Highmark Affordable Care Act, Medicare Advantage, or Commercial Plan

Exclusion Criteria

Not eligible if ANY of the following apply:

Pregnancy
Active cancer treatment
Long-Term Acute Care: Care in Long-Term Acute Care (LTAC)
Skilled Nursing Facility (SNF) residence
Personal Care Home (PCH) residence
Institutionalization
Hospice enrollment
Transplant: Organ transplant
Chronic Kidney Disease stages 3, 4, or 5
End Stage Liver Disease
Cystic Fibrosis
Alzheimer's disease
Dementia
LVAD: Left Ventricular Assist Device (LVAD)
Excluded plan types: Enrolled in a Medicaid, Federal Employee Program (FEP), Medigap, or CHIP plan

Provider Actions

Documentation Required

Eligibility confirmation and exclusions

Document and confirm the member is age 18 or older, has a diagnosis of congestive heart failure (CHF), and is enrolled in a Highmark Affordable Care Act, Medicare Advantage, or Commercial plan. Verify the member does not meet any exclusion criteria (pregnancy; active cancer treatment; care in LTAC, SNF, PCH, or other institutional settings; hospice enrollment; organ transplant; CKD stages 3–5; end stage liver disease; cystic fibrosis; Alzheimer’s disease or dementia; LVAD; or enrollment in Medicaid, FEP, Medigap, or CHIP).

Document patient age (≥ 18).
Document CHF diagnosis.
Document plan type (Highmark ACA, Medicare Advantage, or Commercial).
Confirm absence of any listed exclusion conditions prior to enrollment.

Prior Authorization

Enrollment / Referral pathways

Refer or enroll the clinician's patient (or the patient) by calling 1-855-506-0856, through the MyHighmark app or member website, or by submitting a provider referral via the Availity Essentials portal.

Phone: 1-855-506-0856
MyHighmark app or member website
Provider referral through Availity Essentials portal

Documentation Required

Consent for information sharing

Obtain a member-signed request for information if provider reports or direct contact with the member's provider are requested; Vida can provide reports to the physician only when the patient has signed the authorization.

Member-signed request for information is required to allow Vida to contact the provider.

Billing Rule

Potential member cost sharing

Program services are provided at no cost to qualifying patients; however, copays and deductibles may apply for provider appointments or medications according to the member's benefit design (for example, members with qualified high-deductible plans may pay out of pocket until their deductible is met).

Program services free to qualifying patients.
Copays/deductibles may apply for provider visits or medications per member benefit design.

Background, Evidence & Definitions

The CHF Management program uses 1:1 coaching, digital tools, clinician collaboration, and education resources to improve patient outcomes. Services include live virtual 1:1 support from personal health coaches who work directly with the patient’s provider, education, symptom management, fitness tracking, nutritional support with registered dietitians, mental health assessments, and devices such as digital scales and blood pressure monitors. The program is free to patients who qualify; copays and deductibles may apply for provider appointments or medications per member benefit design.

Vida is a separate company that provides the cardiometabolic condition management services (the CHF program). Highmark contracts with Vida to provide the service and contracts with Availity to provide provider portal services and referral access.

Evidence cited includes a third-party validated actuarial analysis and Vida Health Book of Business analyses for a payer client in 2021 and 2022, which support reported program outcomes such as a 15% reduction in hospital admissions, up to 8% reduction in ED visits, and improved physician engagement (1 in 2 previously non-adherent patients becoming adherent).

Term	Definition
Vida
A separate company that provides cardiometabolic condition management services for eligible members.
Availity
Independent company contracted by Highmark to provide provider portal services.

Why should I use this?

- Intensive program leads to behavior changes, improved clinical outcomes, increased provider engagement, and increased adherence to medications and care.

When should my patient enroll vs. seeing a Specialist?

- Patients should see their Specialist to manage CHF. If patients are unable to see their provider within 14 days, they could have a virtual visit through Vida.

How will I receive information regarding the progress of my patient?

- Vida can provide reports to the physician as requested. Patients must sign a request for information to allow Vida to contact the patient’s provider.

How to enroll or refer:

- Clinician or patient can call 1-855-506-0856, use the MyHighmark app or member website, or submit a provider referral through the Availity Essentials portal.

OpenPayer

Congestive Heart Failure (CHF) Management Program (Vida Health)

Coverage Summary

Medical-Necessity Criteria

Provider Actions

Coding

Background, Evidence & Definitions

Revision History