A
W I N T E R
2 0 1 6
P U B L I C A T I O N
O F
L I F E , H E A LT H & W E L L N E S S
My mother and my grandmother were the two strongest women that I knew. Life experiences help Danelle Hoag support Network Health members
life 3 Ring in a Healthy 2017
How to stay motivated all year
4 Clinical Practice Guidelines Appropriate care for specific clinical circumstances
03
4 Breaking Down Obstacles to Care
Overcome obstacles in your treatment plan
05
health
5
One-on-One Help to Live Better
Individualized support when you need it the most
6 Ensuring the Service You Deserve
Which is right for you right now?
Independent Review
Your right to have certain Network Health decisions independently reviewed S
Making Health Insurance
C O V E R Y
08 12 Common Questions About
the Flu Shot
Preparing yourself and your family for flu season
Chief Administrative Penny Ransom Officer
Marketing Jessica Coordinator Thomaschefsky
Lead Designer Debra Sutton
EDITORIAL BOARD Mark Geiger, Renee Corral, Darren Brzozowski, Melanie Draheim, Gary Melis, Carisa Satorius, Stacy Schwandner, Joan Merwin, Jessica Fischer
TELL US WHAT YOU THINK
T O
wellness
President Coreen and CEO Dicus-Johnson
© 2016 Network Health. No portion of this newsletter may be reproduced without written permission from Network Health.
7 Your Right to Request an
Balance is published by Network Health. The health information contained in Balance is meant to supplement, not replace, the advice of health care professionals.
What to do if you have a concern
7 Emergency Room or Urgent Care
E DITORIAL STAFF
personal
Life experiences help Danelle Hoag support Network Health members
If you have questions or suggestions or would like to tell us how Network Health improved your life, send us an email at
balance@networkhealth.com. You can also write to us at: Network Health Attention: Jessica Thomaschefsky 1570 Midway Pl. Menasha, WI 54952
HAVE A QUESTION?
15 The Damaging Effects of Alcohol
Call our award-winning customer service team.
HOURS Mon., Wed.–Fri.: 8 a.m. to 5 p.m. Tuesday: 8 a.m. to 4 p.m.
and Drug Addiction
Health and financial consequences of addiction
16 A Focus on Quality Care
12 How Do Health Plans Make
Their Decisions?
Network Health’s decision-making process
Learn about our national rankings
17 Preventive Services Helping you live the healthiest life possible
PLANS THROUGH AN EMPLOYER 800-826-0940
13 Your Primary Care Physician
18 What You Need to Know About
PLANS FOR INDIVIDUALS AND FAMILIES 855-275-1400
WANT MORE HEALTH TIPS?
How Network Health assigns a primary care provider
Cholesterol
Control your risk factors for high cholesterol
14 Know Your Numbers
19 Enjoy the Convenience of Virtual
Doctor Visits
Convenient care for covered health services
Control your risk factors for high blood pressure
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Check out our blog at copilotwi.com. We add helpful information about health and well-being every week, so be sure to visit often.
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life
Information to help you get the most out of your coverage
Ring in a Healthy 2017 ‘T
is the season for New Year’s resolutions. One of the most popular resolutions is to get healthy and that includes losing weight and/or getting in shape. Everyone knows the benefits of getting healthy, and most of us want to. The challenge isn’t always physical, it’s also mental. Try these helpful tips to get and stay motivated.
Start Small
It’s common for people to give up on their health goals because they set unrealistic expectations at the start. If you haven’t gone for a run in years, don’t plan on running a marathon in a month. Start small and make a few simple weight loss and exercise changes each day. Over time, these small changes can add up to big results. By setting realistic goals, your chances of success will increase.
Move More, Sit Less
Sitting and smoking have similar negative effects on your health. Make it a point to move more every day, especially if you regularly sit for long periods of time. Park at the back of the parking lot, take the stairs instead of the elevator or walk your dog for an extra 10 minutes each day. When you see an opportunity to move, take it.
Manage Temptation
Nobody is perfect. Remember, there are going to be days when you don’t make it to the gym or you cheat on your diet. Don’t be too hard on yourself. Accept that you will have bad days and commit to be better the rest of the week. Take steps to prevent lapses. Don’t surround yourself with junk food, instead, snack on fruits and veggies. If you know you’ll have to miss a workout, take a quick 20-minute walk over lunch or right when you get home. Even a short amount of exercise is better than none at all.
Celebrate Milestones
It’s easy to get so caught up with reaching a specific health goal that any positive experiences you have along the way get ignored or overlooked because you haven’t quite reached your goal. Problems can begin when the goal becomes your sole purpose in life. Take time to reflect on what’s gone right along your journey to a healthier you and celebrate your accomplishments. n e t w o r k h e a l t h . c o m
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life
Clinical Practice Guidelines
N
etwork Health provides clinical practice guidelines to help you and your health care team make decisions regarding appropriate care for specific clinical circumstances. These circumstances may be medically acute or chronic in nature, such as low back pain, diabetes, or behavioral health like depression. These evidence-based guidelines are available to both you and your provider on Network Health’s website. Go to networkhealth.com and access the guidelines by selecting Member’s Corner. Select Resources and click on the Learn More button. Here you will find a link for Clinical and Preventive Guidelines. If you would prefer a printed copy of these guidelines, call our customer service department at the number listed on page two.
S AY W H AT ?
Acute – Symptoms appear, change or worsen suddenly.
Chronic – Symptoms develop and worsen over time.
Breaking Down Obstacles to Care We understand there may be things that keep you from following or understanding a treatment plan prescribed by your physician. These obstacles may include the following.
• Beliefs and concerns about the condition and treatment
• Perceived barriers to meeting treatment requirements
• Access, transportation and financial barriers to obtaining treatment
• Cultural, religious and ethnic beliefs
All of these factors play into a person’s ability to follow their doctor’s treatment plan. If you are unable to follow your treatment plan because of one or more of these barriers, and need additional support, call our care management department at 920-720-1600 or 800-236-0208. A nurse will help you find ways to work through these barriers.
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health
News and tips to help you maintain a healthy and happy life
One-on-One Help to Live Better
N
etwork Health offers case management benefits to its members at no added cost. Through this voluntary program, experienced nurses and social workers, also known as care management coordinators, support individuals in improving their overall health, navigating the health care system and getting needed services in an optimal, cost-effective setting. Care management coordinators work closely with individuals to help manage their health conditions, prevent complications and disease progression and meet their health goals. Members with complex chronic conditions or illnesses that could lead to high-risk conditions or increased use of health care services could benefit from case management. These conditions can include any of the following. n Complex chronic diseases such as metastatic cancer or end-stage renal disease n Catastrophic or rare conditions such as premature infancy, high-risk pregnancy, trauma or spinal cord injury n Conditions requiring an organ or stem cell transplant n Major complications from a surgery or an extended hospital stay n Multiple physician specialists involved in care n Multiple specialty equipment needs at home
How does the program work?
“
I’m working with individuals to make things easier all the way around.
“
Members who might benefit from case management can be referred by their physician or caregiver, refer themselves or Network Health may identify them through claims or utilization processes. Members who are eligible and agree to participate are enrolled in the program. Once enrolled, care management coordinators work with members to identify their health care needs, develop goals based on their values and helps them meet those goals. Care management coordinators are available by calling 800-236-0208 from 8 a.m. to 5 p.m., Monday through Friday.
Yvonne Morrow, RN Avid runner, single mom and oncology care manager at Network Health View Yvonne’s story at networkhealth.com/Yvonne
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Ensuring the Service You Deserve I
f you have a concern about any services provided by Network Health, contact our customer service department at the phone number on page two and a representative will review your situation and help resolve the issue. It’s very important to us that you receive the service you need and deserve. We believe it’s a big part of the reason our customers rate us higher than the Wisconsin and national average for customer service. If your complaint cannot be addressed immediately, the representative will offer to explain the complaint process to you. If you choose to file a formal complaint, it will be forwarded to a member advocate for a complete investigation that typically involves requesting medical records (if needed) and speaking with the individuals or facilities involved. The member advocate will contact you with the outcome.
“
It’s almost like they wrote the job description just for me. Given my own life experiences, I relate on so many levels. I can sympathize with our members. I’m great at listening and giving them that reassurance they need, whether it’s about a claim or just to be there when they want to talk about their situation or vent a little bit.
“
Danelle Hoag Member advocate at Network Health
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networkhealth.com
For a complete list of recent changes to our provider network, go to networkhealth.com/providerchanges.
Emergency Room or Urgent Care
ER UC or
Which Is Right for You Right Now? I
f you get hurt or become very ill, panic and confusion can make it difficult to know what to do. If you feel you’re experiencing a medical emergency, it’s important to get to the nearest emergency room or call 911. But, sometimes you might not be sure if it’s an emergency. If it’s not, many times your primary care doctor or an urgent care walk-in clinic can help. Here are the answers to two of the most common questions we get about knowing which type of care you need.
What’s the difference between emergency care and urgent care?
Emergency care and urgent care are not the same. An emergency is an illness, injury, symptom or condition so serious, that a reasonable person would seek care right away to avoid serious harm. Urgent care is for an unexpected injury or illness that is not life threatening, but still needs attention quickly so it doesn’t develop into a serious problem. You typically receive emergency care at the emergency room. You may get urgent care at your main doctor’s office, a walk-in clinic or an urgent care facility. You can also get help with some non-urgent situation by using virtual doctor visits (see page 19 for more details about this new benefit).
What if I’m not sure if it’s an emergency?
Knowing what to do before an emergency can help you make the right decision quickly. You can call our 24-hour hotline to speak with a nurse for advice. Call the Network Health Nurse Line at 888-879-8960 for advice about symptoms and when to seek care (TTY 888-833-4271).
Don’t forget to ask questions
Anytime you visit the emergency room, a walk-in clinic or see your primary care doctor, don’t be afraid to ask questions. Asking questions about your care is the best thing you can do to ensure your safety. If something doesn’t seem right or make sense, ask about it. Remember, there’s no such thing as a dumb question, especially when it comes to your health. Your coverage for each of these services may be slightly different depending on your plan. Be sure to call customer service to verify your benefits. Hours and contact information can be found on page two.
YOUR RIGHT TO REQUEST AN INDEPENDENT REVIEW
W
e work hard to ensure your satisfaction, but it’s important to know you have the right to have an independent organization examine certain final decisions made by Network Health. Decisions made by Network Health eligible for review are those where we determined the requested care or services did not meet our requirements for the following. • Medical necessity (care that is reasonable, necessary • Health care setting or appropriate based on proven clinical standards) • Effectiveness • Appropriateness • Level of care • Coverage denial determination based on • Cancellation of a policy or a certificate preexisting condition exclusion • Experimental treatment For more information on the independent review process at Network Health, refer to your certificate of coverage or policy, or contact our customer service department at the phone number on page two.
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S T O C O V E R Y
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networkhealth.com
Making Health Insurance
personal
When you first meet Network Health Member Advocate Danelle Hoag, you immediately feel energized. It’s the spring in her step, her electric smile and the friendly, “Hi, I’m Danelle,” as she enters the room. After you get to know her, you realize there’s something much deeper and more meaningful behind her energy and that smile. It’s what drives and defines her, both personally and in her work with Network Health members. > > > By Jessica Thomaschefsky P h o t o g r a p h s b y B e t h D e s J a r d i n , Tr ove P h o t o g r a p hy
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“A great day for me is when I’m able to help someone, whether it’s at work, my family, a friend or even a stranger,” Danelle said. For Danelle, helping others has been part of her life since she was a young girl growing up in Appleton with her sister and mom. “My mom raised us as a single parent,” Danelle said. “She was bipolar, so there were a lot of things she couldn’t do for us or with us. It was pretty tough at times, especially since bipolar disease—and mental illness in general—is so misunderstood by most people.” Danelle was five years old when her mother was diagnosed, and at the time, mental illness was rarely talked about and even less understood than today. “I was very close to my grandma,” she said. “She was like my other parent.” Her mother’s illness was unpredictable and day-by-day. She never knew if it was going to be a good or bad day. On bad days, her grandmother would step in and take , n o t y Danelle and her sister to church or shopping. Her grandmother sold life insurance as er, Pe t h g u her career, and Danelle remembers going along with her grandma on some of her r da on nd he in Applet a sales calls. Everyone at the office knew Danelle, and she even went to work with e l l Dane Park h a her grandmother during Take Your Daughter to Work Day. They would do a little l u l at Te work, go out for lunch and then do some fun activities afterwards. Danelle, her sister and her grandmother had a very close and loving relationship. Danelle feels lucky to have had her grandmother to care for her when her mother couldn’t. When Danelle was only seven, her family suffered a major setback: her grandmother was diagnosed with ovarian cancer. “I knew I needed to help out any way I could.” Early on, Danelle’s mother and older sister were primary caregivers to her grandmother, but soon, Danelle had to get more involved. Her mother’s own illness was too much for her mother to handle, and her sister had graduated from high school. At the age of 13, Danelle became her grandmother’s primary caregiver. When asked how it felt to be a caregiver at such a young age Danelle replied, “I put them before myself because they needed me. It was just normal, and I didn’t know anything different. They needed me, and I was there.” After high school, Danelle enrolled at the University of Wisconsin–Stevens Point to pursue a degree in broadcast journalism, the perfect career for someone with her outgoing personality. After one semester in college, she returned home after another tragic setback. “Three weeks after I started at UW–SP, my mom died suddenly of complications from pneumonia,” Danelle said. “She was only 42. At the same time, Grandma was in the final stages of her 13-year battle with cancer. So in September 2001, I lost my mom, and my grandma died in April 2002.” After losing two people so close to her in such a short span of time, Danelle was at a crossroads. “I was definitely forced to grow up fast, made to learn things on my own and navigate my life,” she said. “I could have taken a really bad road after all these things happened, but I chose to pick everything up and take care of myself and also to put my efforts into helping others.” Danelle began her career at Network Health in customer service in March 2006 and is now a member advocate. In her role as a member advocate, she plays equal parts detective, attorney, counselor and caregiver. “I’m really the voice of the member with the company,” she says. “I’m kind of a go-between. It’s my job to make sure both the member and Network Health are following guidelines and identifying any mistakes or oversights that may have occurred in the claims process. I’m usually the member’s last step in the appeals process, and for me and Network Health, it’s important that I educate the member on their current situation. I also help them understand what they need to know going forward to make sure their claims are submitted and handled properly.” Looking back, it’s as though Danelle was born to work at Network Health. “It’s almost like they wrote the job description just for me,” she said. “Given my own life experiences, I relate on so many levels. I can sympathize with our members. I’m great at listening and giving The Hoag them that reassurance they need, whether it’s about a claim or just to Family 20 16 be there when they want to talk about their situation or vent a little bit.” Though reassurance and support have been hard to find at certain 10 | balance • W i n t e r 2 016
networkhealth.com
We’re different. We’re compassionate. We’re about people, individuals and their stories. Danelle Hoag, Network Health
points in Danelle’s life, one person has been with her through most of it, her husband, Glenn. “Prom was our first date,” Danelle said. “He was quiet, and I was the social butterfly. But he’s been with me through everything, all the difficult times, even when I was shutting out others after mom and grandma passed. He’s my rock.” She now has two children, a daughter, Peyten, who is six and a son, Maverick, who is two. She calls them her September angels as they were both born in September. Without her kids, it was always a difficult month for Danelle because of the anniversary of her mother’s passing. “I’m very proud of where I’ve come in my life, and I’m very happy,” she says. “My mother and my grandmother were the two strongest women that I knew. My grandmother was the first licensed woman insurance agent in Wisconsin. She wanted me to be in the insurance industry and my mother wanted me to be in health care. I believe that I made them both happy by working at an insurance company that deals with health care.” “My mother had an illness that prevented her from doing the things that she wanted to in life, but she always encouraged me to be strong and to be the best person I could be,” Danelle said. Today, Danelle uses her personal strength to help members navigate through difficult times and the complexities of health insurance. As a longtime employee, Danelle sees many of the traits she’s carried throughout her life in Network Health. “We’re different. We’re compassionate. We’re about people, individuals and their stories,” she says. “And everyone here just wants to help people. At the end of the day, I feel good about that.”
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wellness
News and tips to help you maintain a healthy and happy life
Common Questions About the Flu Shot I
n the United States, flu season begins as early as October, lasting through the winter and sometimes until the end of May. According to the Centers for Disease Control and prevention (CDC), it’s impossible to predict what the upcoming flu season will be like in terms of timing, severity and length. The best way to prevent the flu is by getting a flu shot. You can also take everyday measures to prevent getting the flu. For instance, keep your distance from people who are sick and wash your hands to reduce the spread of germs. Learn the facts about the flu shot by reading answers to common questions listed below. Who should get a flu shot? According to the CDC, anyone over the age of six months should get the flu vaccine. How does the flu shot work? The flu shot is an injection usually given in the arm, which contains an inactive vaccine made of a killed flu virus. Since the virus in the vaccine isn’t live, the shot enables your body to build up a resistance without actually giving you the flu. Can I get the flu from the flu shot? No, you cannot get the flu from the flu vaccine. According to the CDC, almost all people who receive the flu vaccine experience no side effects. Where is the vaccine available? Flu vaccines are available at most doctor’s offices, clinics, pharmacies and even many employers. You don’t need to schedule an office visit with your doctor to get a flu vaccine, many clinics and pharmacies set aside special days and times to give the vaccine.
Can I get the nasal spray instead of the shot? The CDC recommends that the live attenuated influenza vaccine (LAIV), also known as the nasal spray flu vaccine or FluMist, not be used during the 2016-2017 flu season. As a result, the nasal spray flu vaccine will not be covered as a preventive immunization under Network Health plans.
How Do Health Plans Make Their Decisions?
V
isit networkhealth.com and click Member’s Corner. Next, select Resources, click the Learn More button and then click the How Health Plans Make Their Decisions link. You’ll learn important information about service and appropriateness of care. On the same page, you’ll also find helpful information on how to access our care management staff. To request a printed copy, or if you have any questions, call our customer service department at 920-720-1300 (TTY 800-947-3529) from 8 a.m. to 5 p.m. on Mondays, Wednesdays, Thursdays and Fridays or from 8 a.m. to 4 p.m. on Tuesdays. 12 | balance • W i n t e r 2 016
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Your Primary Care Physician I
f you’d like to select a primary care physician (PCP), please share that information with customer service. If you haven’t or don’t wish to designate a PCP, Network Health relies on claims data to assign PCPs to members. Our system automatically assigns PCPs to members based on doctors you’ve seen the most who are part of your plan, designated as a PCP specialty and accepting new patients. For those who haven’t seen a PCP in two years, our system assigns PCPs based on doctors who are closest to you, part of your plan and accepting new patients. Whether your PCP is selected or assigned, you’ll receive the same high quality care you’ve come to expect, and we will communicate with your PCP to help coordinate your care.
Breathe at ease I Breathe at ease
f you’ve been diagnosed with chronic bronchitis, emphysema or COPD, let us help. Breathe at Ease is Network Health’s proactive condition management program designed to help members avoid flare-ups, control symptoms and potentially improve their lung conditions. It’s intended to supplement a physician’s care with one-on-one support from a respiratory therapist. Breathe at Ease received the 2016 Innovation Award from the Wisconsin Society of Cardiovascular and Pulmonary Health & Rehabilitation. To learn more, visit networkhealth.com/Breathe. Breathe at Ease is available at the following locations. St. Elizabeth Hospital Attention: Robyn West, RRT 1506 S. Oneida St., Appleton, WI 54915 Phone 920-831-1498, Fax 920-831-1281 robyn.west@ascension.org Mercy Medical Center Attention: Robyn West, RRT 500 S. Oakwood Rd., Oshkosh, WI 54904 Phone 920-831-1498, Fax 920-831-1281 robyn.west@ascension.org Affinity Medical Group New London Attention: Robyn West, RRT 1420 Algoma St., New London, WI 54961 Phone 920-831-1498, Fax 920-831-1281 robyn.west@ascension.org Calumet Medical Center Attention: Peggy Nolan, RRT 614 Memorial Dr., Chilton, WI 53014 Phone 920-849-1816, Fax 920-849-7529 peggy.nolan@ascension.org Holy Family Memorial Attention: Sandy Bauman, CRT and Lori Newberg, CRT 2300 Western Ave., Manitowoc, WI 54220 Phone 920-320-4247(4AIR), Fax 920-320-3043 sbauman@hfmhealth.org or lnewberg@hfmhealth.org
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wellness
KNOW YOUR NUMBERS
BLOOD PRESSURE If you are older than 60
If you are younger than 60
If you have diabetes or chronic kidney disease
150/90
140/90
140/90
High blood pressure is common among Americans—nearly one in three U.S. adults has high blood pressure, according to the American Heart Association. Unfortunately, this leads to an increased risk for developing serious health conditions. DON’T BE THE ONE IN THREE
Knowing your numbers and being informed can help you manage risk factors and bring blood pressure under control.
WHAT SHOULD I DO IF I HAVE HIGH BLOOD PRESSURE?
Talk to your doctor. Together, you can decide what steps you need to take to achieve levels that are healthy for you. If your initial blood pressure taken at your doctor’s office is higher than usual, be sure to have it rechecked before you leave.
HOW TO CONTROL YOUR RISK FACTORS n
Lose weight. If you’re overweight, losing even five pounds can help lower your blood pressure.
n
Get active. Regular physical activity can help lower your blood pressure and keep your weight under control.
Don’t use tobacco and limit alcohol. Smoking or chewing tobacco can raise blood pressure. If you smoke, quit. And, only consume alcohol in moderation because too much is a contributing factor of high blood pressure. n
Eat a healthy diet. A diet rich in whole grains, fruits, vegetables, low-fat dairy and low in sodium has been shown to help lower blood pressure. n
Reduce stress. Stress can raise blood pressure temporarily and may lead to overeating and tobacco or alcohol use. If you often feel overwhelmed or stressed, it’s important to identify it and take steps to reduce it. n
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The Damaging Effects of Alcohol and Drug Addiction
A
ddiction is a complex brain disorder in which you have a strong need to have or do something. We hear people talk about their addiction to a certain television show or the latest trilogy of young adult novels. However, when it comes to drugs and alcohol, addiction becomes something much more serious. When someone is addicted to drugs or alcohol, they compulsively seek out and use, despite the consequences. The chemical changes that occur in the brain interfere with a person’s ability to think clearly and feel normal when they do not have drugs or alcohol in their system. For many people, addiction becomes a chronic condition with relapses occurring even after a long period of abstinence. Addiction is increasingly being recognized as a disease, but one that can be treated.
complications affecting every organ in the body. It damages emotional stability, finances, career and family life. The entire community in which an alcoholic or drug abuser lives is also impacted because of the strain on the health care system, the criminal justice system and general public safety.
Cost and consequences
24 hours a day at 800-NCA-CALL or visit ncadd.org. n Reach out to the health and human services division in your Wisconsin county. Most counties provide crisis hotlines and counseling services.
Addiction crosses all social and economic boundaries, affects every ethnicity, both genders and can impact all aspects of a person’s life. Long-term use of alcohol and other drugs can cause serious health n e t w o r k h e a l t h . c o m
Where to go for help
Stopping addiction is not easy, but it’s important to know you are not alone. Alcoholism and drug dependence are complex problems that should be discussed with a doctor. A doctor should be the first person you reach out to. There are also many community resources available.
Extra help is just a phone call or visit away. n Call the National Council on Alcoholism and Drug Dependence
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A Focus on Quality Health Care N
etwork Health evaluates the quality of care and services provided using two nationally recognized tests, the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®).
Each test scores our services in a different way. HEDIS measures preventive care and care for chronic diseases. CAHPS evaluates customer satisfaction with services provided by customer service, claims and physicians. The tables below show Network Health’s excellent ranking on both state and national levels.
How We’re Doing
2016 Reporting Year Network Health HMO/POS (Commercial) HEDIS Results Category/Measure
Network Health Combined Results
Wisconsin Health National Average Plans Average Results Results
Cervical Cancer Screening
78.60%
74.70%
73.21%
Colorectal Cancer Screening
73.56%
67.19%
59.99%
Childhood Immunization Status Combo 5
82.88%
74.44%
64.00%
Adolescent Immunization – Tdap/Td
94.68%
89.96%
81.55%
Prenatal and Postpartum Care Postpartum Care
91.62%
81.12%
68.17%
Comprehensive Diabetes Care Eye Exam Performed
71.02%
59.09%
50.42%
Comprehensive Diabetes Care HbA1c Tested
95.98%
93.47%
89.47%
Comprehensive Diabetes Care HbA1c Level less than 7%
44.73%
38.75%
35.39%
How You Rate Us
2016 Reporting Year Network Health HMO (Commercial) CAHPS Results Network Health Combined Results
Wisconsin Average
National Average
Category/Measure Customer Service – Composite Score
90.87%
90.03%
87.48%
How often did your health plan’s customer service staff treat you with courtesy and respect?
95.08%
95.38%
94.08%
How often did your health plan handle your claims correctly?
94.00%
89.65%
88.99%
How often did you get an appointment to see a specialist as soon as you needed?
86.47%
84.68%
84.47%
How often did your health plan’s customer service give you the information or help you 86.67% needed?
84.69%
80.83%
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2017 Quality Program Information Each year, Network Health’s Quality Improvement (QI) department updates its quality improvement program structure to ensure our members are receiving high quality care and includes the following. n
A written description of the quality improvement program n Specifically addressing behavioral health care n Specifically addressing patient safety and quality of care n Specifically addressing 2017 quality programs goals and how we will accomplish the goals to maintain or improve the care members receive n The structure of the quality improvement program, including it’s accountability to the Board of Directors n A designated physician who has substantial involvement and oversight of the quality improvement program n A designated behavioral health care professional who is involved and has oversight of the behavioral health care programs and services n
A quality improvement committee that oversees the function of the organization n The specific role, structure, meeting frequency and function of the quality improvement committee and other connected committees n An annual quality work plan, including progress toward accomplishing goals n A description of resources the organization devotes to the quality improvement program For more information about Network Health’s Quality Improvement Program, call 920-720-1655 or 800-826-0940, ext. 01655. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Preventive Services
T
o help you live the healthiest life possible, certain preventive services are offered at no extra cost for most Network Health members. Preventive services help you identify diseases or medical problems before you show symptoms. These services include screenings, immunizations, lab tests and other services that help you prevent health problems. When you see an in-network doctor for one of the preventive services listed in our Preventive Services Guide, most plans cover preventive services at 100 percent. However, you may be responsible for certain payments (deductible, coinsurance and copayment) if you receive the services for diagnostic reasons. If you are part of a self-funded plan, refer to your Summary Plan Description for coverage details. Any follow-up tests, tests to monitor a chronic disease and any tests not listed in this guide are considered diagnostic. Our Preventive Services Guide will help you understand when certain common services are considered preventive or diagnostic. To view our Preventive Services Guide, visit networkhealth.com/members. Select the Resources button on the right side of the screen and then click Learn More.
How do we determine which services are considered preventive?
Our recommendations for preventive care are based on medical research from nationwide organizations like the U.S. Preventive Services Task Force. These guidelines can change from year to year depending on new research. If you have any questions about Network Health’s preventive services, call our customer service department at the number listed on page two.
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What You Need to Know About Cholesterol A
ccording to the American Heart Association, high cholesterol is one of the major risk factors leading to heart disease, heart attack and stroke. The health risks associated with high cholesterol are not immediate, as damage accumulates over years or even decades. Here’s what you need to know about cholesterol, risk factors and how to manage your levels.
WHAT IS CHOLESTEROL?
Cholesterol is a wax-like substance found in the fats (lipids) in your blood. Your body needs cholesterol to continue building healthy cells, however, when your cholesterol is high your risk of heart diseases increases.
Types of cholesterol (fats) in your blood Low-density lipoprotein (LDL)
High-density lipoprotein (HDL)
Triglycerides
The only way to know if you have high cholesterol is to have a blood test, called a lipid panel or lipid profile.
• Also known as “bad” cholesterol • Builds up in the walls of your arteries, making them hard and narrow • Increases your risk of heart disease • Used by your body as a source of energy • High levels of triglycerides are unhealthy • Produced in the liver
• Also known as “good” cholesterol • Picks up excess cholesterol and takes it back to your liver • High levels can help protect against heart attack and other cardiovascular complications
RISK FACTORS
Smoking – Cigarette smoking damages the walls of your blood vessels, making them likely to accumulate fatty deposits. Smoking may also lower your level of HDL “good” cholesterol. Obesity – Having a body mass index (BMI) of 30 or greater puts you at risk of high cholesterol. Poor diet – Foods that are high in cholesterol, such as red meat and full-fat dairy products, will increase your total cholesterol. Eating saturated fat and trans fats can also raise your cholesterol level. Lack of exercise – Exercise helps boost your body’s HDL “good” cholesterol while lowering your LDL “bad” cholesterol. Not getting enough exercise puts you at risk of high cholesterol.
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High blood pressure – Increased pressure on your artery walls damages your arteries, which can speed the buildup of fatty deposits. Diabetes – High blood sugar contributes to higher LDL cholesterol and lower HDL cholesterol. High blood sugar also damages the lining of your arteries. Family history of heart disease – If a parent or sibling developed heart disease before age 55, high cholesterol levels place you at a greater-than-average risk of developing heart disease. Take steps to lower your cholesterol and reduce your risk of heart disease and stroke by managing your cholesterol levels with healthy lifestyle choices and a medical treatment plan when prescribed by your doctor.
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Enjoy the Convenience of Virtual Doctor Visits E
ffective January 1, 2017, Network Health members will have access to virtual visits through our virtual provider network, MDLIVE®. Virtual visits are a convenient way to get care for covered health services that include the diagnosis and treatment of non-urgent medical conditions through electronic means. MDLIVE, offered through most Network Health plans, is designed as an alternative to expensive urgent care visits or waiting to get an appointment with your primary care physician (PCP) for non-emergency medical conditions. You can consult with a board-certified doctor by phone, secure video or MDLIVE App—anytime, from anywhere. Licensed therapists are also available by appointment via secure video. The average wait time for a virtual visit is less than 10 minutes. All MDLIVE doctors are U.S. board certified, have on average 15 or more years of experience and are able to treat a wide range of conditions like those listed below.
Non-emergency conditions treated by MDLIVE ■ Allergies ■ Cold and flu ■ Constipation ■ Cough
■ Diarrhea ■ Ear problems ■ Fever ■ Headache
MDLIVE doctors can prescribe non-narcotic medication (if needed) and send e-prescriptions to an in-network pharmacy. Any prescriptions written by the provider will be covered under the pharmacy benefit of your plan. You can access MDLIVE by logging in to networkhealth.com/ MyAccount and clicking on the MDLIVE Virtual Visits link. For most plans with primary care visit copayments, a virtual doctor visit will cost between $0–$20 (less than a primary care visit). All virtual doctor visits will cost no more than $41 and you’ll see your cost once
■ Insect bites ■ Nausea and vomiting ■ Rash ■ Respiratory problems
■ Sinus problems ■ Sore throats ■ Urinary problems or UTI
signed into your account. For more details about your plan, see your member materials. All of the doctors you access through MDLIVE are considered in network. MDLIVE is not intended to replace your primary care doctor or to be used in life-threatening emergencies. You should not use MDLIVE if you are experiencing a medical emergency. In case of a lifethreatening emergency, dial 911 immediately.
MDLIVE does not replace the primary care physician. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. MDLIVE interactive audio consultations with store and forward technology are available 24/7/365, while video consultations are available during the hours of 7 a.m. to 9 pm seven days a week or by scheduled availability. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit www.mdlive.com/pages/terms.html 120115 © 2016 MDLIVE, Inc. All rights reserved. V.42716 n e t w o r k h e a l t h . c o m
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1570 Midway Pl. Menasha, WI 54952
MAILED ON 12/31/16
I want “
to make sure our members get the best care.
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My name is Laura, and I work at Network Health. Ever since I was a little girl, I wanted to be married and I wanted to be a mom. This is what I’ve always wanted for myself. I worry about my daughter and making sure she gets the care that she needs, so I want to make sure our members get the best care. These are families—this is someone’s son, daughter, brother, sister, mom or dad. We want to make sure we’re keeping things as simple as possible.
Watch Laura’s story at networkhealth.com/Laura networkhealth.com | 800-276-8004
HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health Insurance Corporation, or Network Health Insurance Corporation and Network Health Plan. Self-funded plans administered by Network Health Administrative Services, LLC. SAL-381-01-11/16