CurrentHighmark PennsylvaniaPolicy N/A

COPD Management program — Coverage Criteria

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Defines Highmark Pennsylvania's COPD Management program offering virtual 1:1 coaching, digital tools, clinician collaboration, and education for eligible members with COPD. Affects clinicians, referring providers, and Highmark members enrolled in specified plan types.

Policy Summary

PayerHighmark Pennsylvania

PolicyCOPD Management program — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRefer eligible patients (age ≥18 with COPD who do not meet listed exclusions) via phone 1-855-506-0856, MyHighmark, or Availity Essentials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15%hospital admissions reduction

up to 8%ED visits reduction

1 in 3inhaler adherence

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CurrentHighmark PennsylvaniaPolicy N/A

COPD Management program — Coverage Criteria

Customize your policy alerts

Sign up for all Highmark Pennsylvania policy alerts

Know when Highmark Pennsylvania releases new policies or updates existing guidance.

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Policy Summary

PayerHighmark Pennsylvania

PolicyCOPD Management program — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRefer eligible patients (age ≥18 with COPD who do not meet listed exclusions) via phone 1-855-506-0856, MyHighmark, or Availity Essentials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15%hospital admissions reduction

up to 8%ED visits reduction

1 in 3inhaler adherence

Coverage and Eligibility Criteria

Enrollment eligibility

Covered when ALL of the following are met

Age and diagnosis: Patient is age ≥ 18 and has a diagnosis of COPDage >= 18

Inclusion criteria: patients ≥ 18 y/o with COPD

Plan eligibility: Patient is enrolled in a Highmark Affordable Care Act (ACA), Medicare Advantage, or Commercial planplan in {ACA, Medicare Advantage, Commercial}

Accepted plan types listed in inclusion criteria

Program participation prerequisites: Patient is willing to participate in the COPD Management program components (virtual 1:1 coaching, education, symptom management, and use of provided digital monitoring devices)n/a

Program components described in source to define expected participation

Exclusion conditions for the COPD Management program include members who are pregnant; undergoing active cancer treatment; residing in or receiving care in a long-term acute care (LTAC) facility, skilled nursing facility (SNF), or personal care home (PCH); who are institutionalized; receiving hospice care; have had a transplant; or have specified serious comorbidities including CKD stages 3–5, end stage liver disease, cystic fibrosis, Alzheimer’s disease or dementia, or left ventricular assist device (LVAD).

Members enrolled in Medicaid, Federal Employee Program (FEP), Medigap, or Children’s Health Insurance Program (CHIP) plans are also excluded from program eligibility.

The document’s exclusions are written to identify members who are not eligible for enrollment rather than to provide explicit not medically necessary (NMN) determinations. In other words, the listed conditions and plan types describe ineligible members rather than formal NMN medical necessity decisions.

Provider Steps, Referrals, and Denial Triggers

Prior Authorization

Prior authorization / cost note

No prior authorization is required for enrollment in the Vida program. The program is free to qualifying patients; however, standard copays and deductibles may still apply for any provider appointments or medications associated with care.

Program does not require prior authorization
Program free to qualifying patients; copays/deductibles may apply for related provider visits or medications

Note

Interim virtual visit pathway

If a patient cannot see their specialist within 14 days, an interim virtual visit through Vida may be used until the member can be seen by their regular specialist.

Use Vida virtual visit as interim when specialist appointment >14 days

Program Background and Rationale

The COPD Management program is a multi-component intervention that pairs patients with live, virtual 1:1 health coaching and integrates digital monitoring tools and clinician collaboration. Program components include: personalized coaching to support symptom management and medication adherence; use of digital monitoring devices to track relevant clinical data; structured communication and information-sharing with the member’s clinician; and patient education addressing self-management, nutrition, and mental health support. These components aim to improve adherence and reduce acute care utilization (for example, fewer hospital admissions and emergency department visits) among engaged patients.

Key Definitions

COPD Management program — definition

DefinitionA multi-component intervention using 1:1 coaching, digital tools, clinician collaboration, and education resources to improve outcomes for patients with COPD.

Core componentsLive virtual 1:1 support from personal health coaches who work directly with the patient’s clinician; digital monitoring tools; educational resources for self-management.

Primary goalsImprove medication adherence, reduce unplanned hospital admissions and avoidable ED visits, and support symptom management and nutrition/mental health needs.

Intended populationAdults with COPD enrolled in eligible Highmark plans (see coverage criteria).

Care coordinationHealth coaches collaborate with the patient’s clinician and can share progress reports to the physician upon patient-signed request for information.