L I F E , H E A LT H & W E L L N E S S
A PUBLICATION OF
FA L L 2 016
Hitting the Road Follow along as one Network Health agent becomes a Medicare member
inside LIFE
Breaking Down Obstacles to Care
HEALTH
Ensuring the Service You Deserve
WELLNESS
Join Us for Network Health’s Member Appreciation Events
Important 2017 Benefits Information Begins on Page 20 Good News About Our Provider Network
Exclusive Reduced Rates for Network Health Medicare Advantage Plan Members
The Sound of Music – December 14, 2016 at 7:30 p.m. The Bodyguard – January 22, 2017 at 1 p.m. Vienna Boys Choir – February 24, 2017 at 7:30 p.m. For ticket prices and offer details, visit foxcitiespac.com/onlineoffers. Click the Network Health Medicare Advantage member logo, select Find Tickets, type MEDICARE in the promo code field and follow the instructions to complete your purchase. This limited-time ticket offer is for Network Health Medicare Members and their families only. Not valid on previously purchased tickets. While supplies last. C
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5 Evaluating New Technologies 5 Who Makes Network Health’s Decisions?
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life
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3 Breaking Down Obstacles to Care 3 What Can You Expect? Medicare Scams 4
15 Measuring Our Success 15 A Form Can Save You (And Your Loved Ones) Headaches 16 Combatting Depression
6 Ensuring the Service You Deserve
17 Know Your Numbers - Blood Pressure
8 Emergency Care or Urgent Care Which Is Right for You Right Now?
18 Common Questions About the Flu Shot
9 Network Health Launches New Preventive Colorectal Cancer Screenings
19 Join Us for Network Health’s Member Appreciation Events
FEATURE 10 HITTING THE ROAD Follow along as one Network Health agent becomes a Medicare member
20 Good News About Our Provider Network
wellness 14 Medication Therapy Management 14 Learn More About Preventive Health
18 Your Primary Care Physician
21 2017 Plan Choices and Benefits Learn more about our 2017 plans and exciting new benefits in northeast Wisconsin BACK COVER Meet Stacy Schwandner Manager of Individual Customer Service
Y0108_914r1_090916 Accepted 09182016 EDITORIAL STAFF President and CEO Coreen Dicus-Johnson Chief Administrative Officer Penny Ransom Marketing Coordinator Kari Navis Lead Designer Debra Sutton
Network Health offers TDD/TTY services for deaf, hard of hearing or speech-impaired individuals. Anyone needing these services should call 800-947-3529. Bilingual language assistance or translation services are also available. Callers may leave a message 24 hours a day, seven days a week.
ASK NETWORK HEALTH If you have questions about anything you read in this issue of Concierge, call customer service at 800-378-5234 Monday–Friday, 8 a.m. to 8 p.m. From October 1–February 14, we’re here every day, 8 a.m. to 8 p.m. You can also learn more at NetworkHealthMedicare.com.
Concierge is a biannual publication of Network Health. The health information contained in Concierge is meant to supplement, not replace, the advice of health care professionals. © 2016 Network Health Insurance Corporation. No portion of this newsletter may be reproduced without written permission from Network Health Insurance Corporation.
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life
Breaking Down Obstacles to Care
T
reatment plans are only helpful if you follow them. What if your doctor’s orders conflict with your religious beliefs or create tension with your cultural practices? What if you can’t afford the treatment? If you find yourself facing decisions between following your beliefs or your doctor’s instructions or you are struggling to pay for treatment, Network Health can help. Network Health’s care management team helps people overcome barriers to treatment requirements every day, including the following. n Beliefs and concerns about your condition and treatment n Access, transportation and financial barriers to obtaining treatment n Cultural, religious and ethnic beliefs that conflict with treatment Call 866-709-0019 (TTY users call 800-947-3529) to speak with a nurse who can help make your treatment plan fit the rest of your life.
Yvonne Morrow, RN Avid runner, single mom and oncology care manager at Network Health View Yvonne’s story at networkhealth.com/Yvonne
What Can You Expect?
When you experience a sudden or long-lasting illness, it’s normal to want more information. Where can you look to learn more about the standards of care you can expect? Network Health provides clinical practice guidelines to help you and your doctors make decisions regarding appropriate health care for some conditions. These conditions may be sudden (acute) or long-lasting (chronic) and include medical topics such as low back pain and diabetes, as well as behavioral health conditions, including depression. These evidence-based guidelines are available to both you and your doctor on Network Health’s website. Visit NetworkHealthMedicare.com to access the guidelines. Select Member’s Corner, and click Clinical and Preventive Guidelines under Resources. If you have any questions about the standard of care you are receiving after discussing with your doctor, call a member of our health care concierge team. NetworkHealthMedicare.com
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life
Medicare Scams
Don’t Fall Victim to Medicare Fraud M
edicare fraud costs American taxpayers billions of dollars each year and results in higher medical costs for everyone. As your health care partner, Network Health has some tips to help avoid Medicare fraud.
n Never sign blank insurance claim forms. n Do not do business with door-to-door or telephone salespeople who tell you that services or medical equipment are free or available for no direct cost to you. n Only give your insurance/Medicare identification and Social Security numbers to those who have provided you with medical services. n Keep accurate records of all your health care appointments and verify your explanation of benefits and all bills for services. n Always watch your credit card and bank statements for any improper billing activity or fraudulent withdrawals. n Monitor your credit report regularly. Sometimes people do not report scams because they are ashamed or embarrassed. It is important to know, it’s not your fault. If you feel you are the victim of an insurance scam, we are here to assist you. Call a member of our health care concierge team or email us at paymentintegrity@networkhealth.com.
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emember, you can always call our Values Line to report and discuss activities or occurrences you believe are improper. The hotline is confidential, and you may report concerns anonymously. Your concerns will be investigated and appropriate action will be taken to address the problem.
The Values Line number is 800-707-2198. 4 | C oncierge
NetworkHealthMedicare.com
Evaluating New Technologies N
etwork Health evaluates new technology and new applications of existing technologies on a regular basis. This includes the evaluation of medical procedures, drugs and devices. Decision making on technologies is based on, but not limited to the following. n n n n n n n n n
Medicare guidelines U.S. Food and Drug Administration (FDA) approval Manufacturer information Scientific evidence Peer-reviewed articles Opinion of contracted providers Risk/benefit analysis Government regulatory agencies Assessments performed by agencies specializing in technology
New technologies are reviewed by a group of participating physicians and health plan staff (Medical Policy Committee) who make recommendations for inclusion as a covered benefit. The following technology assessments have been reviewed over the past 12 months. Remember, final coverage decisions are made based on Medicare guidelines. n n n
Cologuard (colon cancer screening test) – Determined to be safe and appropriate for those who meet the specific medical criteria Intacs (corneal implants for keratoconus) – This technology is safe and effective and a medical policy has been developed Corus CAD (blood test to assess if chest discomfort or other symptoms may be due to obstructive coronary artery disease) – This technology remains experimental and investigational
If you have a question about a technology assessment, call a member of our health care concierge team.
Who Makes Network Health’s Decisions?
D
o you know how health plans make their decisions? Visit NetworkHealthMedicare.com and click on Member’s Corner. Next, scroll down to Resources and click How Health Plans Make Their Decisions. 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 about Network Health’s utilization management process, decisions or criteria, call our utilization management department at 866-709-0019, Monday–Friday, 8 a.m. to 5 p.m. TTY users call 800-947-3529. NetworkHealthMedicare.com
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health Ensuring the Service You Deserve A
t Network Health, we make every effort to ensure you’re receiving the service you need and deserve. We believe that’s a big part of the reason nine out of 10* of our members stay with us. But if concerns arise, we want to make sure you understand all your options.
If you do not agree with Network Health’s decisions about your care or what’s covered, we have a team of member advocates who work proactively to resolve your concerns or complaints. They will work with you to resolve the issue. If a member advocate isn’t able to resolve the issue, you have the right to file a grievance or appeal. You must file your appeal in writing within 60 calendar days after the date of the denial. Although, if you have a good reason for missing the deadline, we can give you more time.
How can I file a complaint?
If you’re dissatisfied with the service or quality provided by your plan or doctor, we’re here to work with you through any issues. You have the right to file a grievance (a formal complaint) about how Network Health provided services. Examples of situations appropriate for a grievance include the following. n Difficulty getting through on the phone n Concerns about the quality of care of services provided n Interpersonal aspects of care (for example, rudeness of a provider or staff) n Failure to respect your rights
Who may file an appeal?
You or someone you name to act for you (called your authorized representative) may file an appeal. To learn how to name your authorized representative see page 15 or call our health care concierge team.
How do I file an appeal?
You can send us your appeal by faxing it to 920-720-1908 or writing to us at the address below.
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Network Health Attn: Appeals and Grievances P.O. Box 120 Menasha, WI 54952 NetworkHealthMedicare.com
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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.
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Danelle Hoag Member Advocate at Network Health
Read Danelle’s story at CoPilotWI.com
What happens after I file an appeal?
If you appeal, we will review our decision. After we review our decision, if payment for any of your claims is still denied, we will automatically forward your appeal request to the CMS Contractor (MAXIMUS Federal Services) for an independent review. This process is provided by Medicare for a new and impartial review of your case outside of Network Health. If you disagree with that decision, you will have further appeal rights and you’ll be notified of those rights from MAXIMUS Federal Services. You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event. Call a member of your health care concierge team or write to Network Health, P.O. Box 120, Menasha, WI 54952. We will complete an investigation as quickly as your case requires and let you know the results no later than 30 calendar days from the date we received your request. If we need more time to make a determination, we’ll let you know about that extension within 24 hours. If you have questions about our member advocate team or filing a complaint, appeal or grievance, contact a member of your health care concierge team. *Based on the percentage of Network Health Medicare Advantage (PPO) members who stayed in the plan for 2016, for coverage starting January 1, 2016. NetworkHealthMedicare.com
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health
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 it’s an emergency, it’s important to get to the nearest emergency room or call 9-1-1. But, sometimes you might not be sure if it’s an emergency. If it’s not, many times your primary care doctor or a walk-in clinic can help.
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 you don’t develop a serious problem.
You typically receive emergency care at the emergency room. You may get urgent care at your primary doctor’s office, a walk-in clinic or an urgent care facility.
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. If you are not sure whether you should go to the emergency room, call your doctor. Network Health members can also call our 24-hour hotline to speak with a nurse for advice.
Don’t Forget to Ask Questions
Anytime you visit the emergency room, a walk-in clinic or see your primary 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.
Call the Network Health Nurse Line at 888-879-8960 for advice about symptoms and when to seek care. TTY users call 888-833-4271. 88 || C Concierge oncierge
NetworkHealthMedicare.com NetworkHealthMedicare.com
Watch for your next issue of Concierge in spring of 2017.
Network Health Launches New Preventive Colorectal Cancer Screenings C
olorectal cancer is the second leading cancer killer, but it doesn’t have to be. Research shows colorectal cancer is highly preventable and treatable when detected early. It affects both men and women, and the risk increases after age 50. Based on recommendations from the American Cancer Society, Network Health recommends men and women who are between 50 and 75 years old have one of the following screenings. n A fecal occult blood (FIT) test – every year OR n Flexible sigmoidoscopy – every five years OR n Colonoscopy – every 10 years We want to help make preventive health as simple as possible for you. To do this, we’ve partnered with a company called BioIQ to offer you an at-home testing kit at no cost. This yearly test is a simple alternative to more extensive screenings like a sigmoidoscopy or colonoscopy. Plus, there are no diet or medication restrictions before taking this test. Enclosed in these kits, members will find directions and the supplies they need to complete this annual screening. As an added convenience, you can complete the test in the privacy of your home. This test looks for traces of blood in your sample. There are several common causes for this other than colorectal cancer. If you receive a positive or inconclusive result, don’t panic. Your next step should be to schedule a follow-up appointment with your doctor to discuss your results. If you are missing one of the recommended screenings, you may receive a kit in the mail. If you have any questions or would like to opt out from colorectal screening reminders, call 866-709-0019, Monday–Friday, 8 a.m. to 5 p.m. TTY users call 800-947-3529. NetworkHealthMedicare.com
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COVER STORY
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HITTING THE ROAD Follow along as one Network Health agent becomes a Medicare member
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hen the kids were younger, we used to tent camp.” Not anymore. Now, John Holdorf is traveling in style. As you read this, there’s a good chance that John and his wife Diane are on the road in their motorhome heading for their next adventure. Earlier this year, they took a two-week tour of the Midwest visiting Ohio’s National Museum of the U.S. Air Force near Dayton, family in Columbus, fishing with friends on Lake Erie and a few days with their son, Eric, and the grandkids in Michigan. When asked what inspired him to buy a motorhome, he said, “It’s something we had in the back of our minds that we wanted to do.” While they’ve had their motorhome for two years, the RV lifestyle still feels new. Until recently, John was working full time. He’s 69 and could have retired earlier. But clearly, he loved his work as an insurance agent, and he wasn’t quite ready to close a chapter after 44 years in the industry. Now that he’s officially retired, John and Diane have more free time to hit the road. When he returned from service in Vietnam, John started his career with American Family Insurance in Oshkosh. He then spent 23 years as an agent for McClone Insurance Agency.
By Kari Navis, Photography by Beth DesJardin, Trove Photography NetworkHealthMedicare.com
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COVER STORY John was one of the first agents at McClone to start selling Medicare Advantage Plans, and the business grew and expanded over the years. He says his favorite part about working in insurance was the people. “I’ve really developed some nice relationships over time. I had some people who were with me the full 44 years.” He loved getting to know people, not just as clients but as friends. Just as he shared this, a woman walked by our table on her way to breakfast. “Good morning, Elaine. How are you doing, dear?,” John asked. She was one of John’s former clients. “It used to drive my kids nuts,” he said. Anytime they would go somewhere as a family, John would run into someone he had worked with. John shared that he had once helped a gentleman in town enroll in a Network Health plan, and John later went to meet him at his house. “I walked in, and the guy almost gave me a hug,” John said. The member had just recently had a major heart attack and was overcome with emotion. “He was just so happy with the way everything had worked out with Network Health. That still sticks in my mind.” As a licensed, independent agent with several Medicare offerings, including Network Health, John knew a lot more than the average consumer when it came time to
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select his own Medicare coverage. He wanted a company that was easy to work with, and after placing many clients with Network Health over the years, John selected Network PlatinumSelect (PPO) for himself. One of the things John loves about his plan is that it’s a PPO (Preferred Provider Organization) plan. This type of coverage allows him to see any doctor who accepts Medicare beneficiaries, whether they are in- or out-of-network. John’s own doctor is a ThedaCare doctor, and he has no plans to change providers or health insurance plans. John and Diane have been seeing the same doctor for 10 years. They are comfortable with him and appreciate that the office is close to home. When John heard that ThedaCare would be out-of-network in 2017, he said, “I wasn’t really concerned about it. Even if they are out-of-network, there’s a maximum out-of-pocket. And copayments, both in- or out-of-network, count toward that maximum out-of-pocket.” “I’ve had a lot of friends and clients go to Aurora, which is out-of-network, and they’ve had no problem at all. It should be the same way with ThedaCare. It’s not going to be an issue.” This past spring, John got a lot of calls from his clients when ThedaCare announced they were ending their
NetworkHealthMedicare.com
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I’ve had a lot of friends and clients go to Aurora, which is out-of-network, and they’ve had no problem at all. It should be the same way with ThedaCare. It’s not going to be an issue. - John Holdorf
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contract with Network Health. His clients were worried, especially in areas with mostly ThedaCare options. “What I told them, was to wait it out. I know Network Health, and they’re going to work something out for us.” No doubt, as a member, John will be glad to see that copayments will be the same for in- and out-of-network providers in 2017 and contribute to a combined maximum out-of-pocket. This is the first fall he won’t be helping his clients make their Annual Enrollment Period selections. But, while retirement has taken some getting used to, he knows his clients are in great hands with his successors. While his former colleagues are busy with the Annual Enrollment Period, John will be making the most of his PPO plan. When he and Diane travel anywhere in the U.S. outside of Wisconsin, any doctor or hospital that accepts Medicare is treated as an in-network doctor, so costs are the same as a local, in-network doctor. There’s international coverage, too. John calls the travel benefit “another big plus” for Network Health. “As long as members have gone to a provider that accepts Medicare, it has never been an issue.” John has had clients he has written HMO policies for with other companies, and they’ve struggled to find a doctor in the area when they’ve been traveling. The plans didn’t have an approved doctor nearby, so his clients had to travel to an unfamiliar area when they had a health concern. If anyone knows health concerns can crop up at any time, it’s John and his family. When his daughter, Amy, was 21, she faced a life-threatening kidney condition seemingly out of the blue. She was in college, and she went to the hospital for high blood pressure. Her doctors discovered she would need a kidney transplant, and John was as worried as any parent would be. Luckily, John’s wife was a good match, and they scheduled the transplant over summer vacation. It’s clear NetworkHealthMedicare.com
by John’s expression, the day the two most important women in his life both underwent major surgery was one of the longest days he has ever experienced. His face relaxes into a smile, and thankfully, John can say it all worked out. His daughter and wife are both doing well now. While his daughter’s condition was unavoidable, John is doing everything he can to sidestep such a serious condition. He takes great care of himself, and fitness is one of his favorite hobbies. He works out at the YMCA five days a week, and his thirty-year habit of staying fit is paying off with good health as he begins to enjoy his retirement. John doesn’t take his health for granted. He knocks on wood as he thinks about what he’s most concerned about medically. His father’s side of the family has a history of heart issues. “My dad passed away at 54. There were three brothers, and he lived to be the oldest of them.” Those losses, while heartbreaking, have provided John with great motivation to live a healthier, longer life. He keeps his friends at the gym informed of his upcoming road trips, because they notice when he’s not there. “When you go to the Y so often, if you don’t show up for a couple days, someone’s on the phone asking if everything’s going okay. That’s something I appreciate.” In addition to staying physically active, staying socially active has become even more important to John since he retired. Whether it’s staying involved in the Rotary Club, volunteering with Meals on Wheels or serving as president of the board at Bethel Lutheran Home Foundation, he looks forward to an active retirement in all aspects of his life. John can adjust to retirement with peace of mind knowing that no matter where his next adventure takes him, he has health coverage for life’s unexpected twists and turns. C oncierge | 13
wellness
Medication Therapy Management
A
s a Network Health Medicare Advantage member, you may be eligible for participation in our medication therapy management program. In fact, if you meet the eligibility requirements, you are automatically enrolled. The program is offered at no cost to you. The medication therapy management program can help you get the best results from your medicines. It might even help you save money on your prescription medications.
To be eligible, the following statements must apply to you. 1. 2. 3.
I have at least three long-term (chronic) medical conditions. I take seven or more daily medicines that are covered by Medicare Part D. My Part D covered medications cost more than $3,507 in 2016 (the CMS-specified annual cost threshold).
If you agreed with all three statements above, you can participate in a comprehensive medication review with a Network Health pharmacist. Watch for an introductory letter that explains how to get started. You will receive a phone call from a pharmacist to discuss your medications in the privacy of your home. Afterward, we’ll send you a letter which you can share with your doctors and health care team. It’s a great opportunity to doublecheck that your medications work well together and are the most cost-effective for your health.
Learn More About Preventive Health I
t can be tough to keep all the recommended preventive care and screenings straight, but they are crucial for early detection and treatment. When was your last physical? How often should you have a mammogram? Have you had your flu shot yet this year? Network Health has a handy chart to help you track care as you receive it. To print a copy of this chart, visit NetworkHealthMedicare.com. Select Member’s Corner, click Benefits for Better Health and click Preventive Health Checklist, under Preventive Care. You can also request a printed copy by calling customer service.
For specific coverage information, refer to your Evidence of Coverage document. Remember, costs and coverage for these services can vary depending on the plan you have. This is especially true for NetworkPrime (MSA) members. NetworkPrime members should refer to their Evidence of Coverage for specific information. If you have any questions about your coverage for these preventive screenings, contact a member of your health care concierge team before you schedule a doctor appointment. 14 | C oncierge
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Measuring Our Success W
hen discussing Medicare Advantage coverage with friends and family, it’s important to compare apples to apples. You need to know both the coverage and service you’ll receive, because your choice is important to your quality of life and health. But, with so many companies and plans to choose from, how can you know you’re making the right choice? Medicare rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare’s CMS Star Rating Program helps you know how well your plan and providers are doing. You can use these Star Ratings to compare quality performance to other plans. For 2016, Network Health Medicare Advantage Plans received the following Overall Star Rating from Medicare.
NETWORK HEALTH SCORED 4.5 OUT OF 5 STARS. Some of the areas Medicare reviews for these ratings include the following. n How members rate the plan’s services and care n How well the plan’s providers detect illnesses and keep members healthy n How well the plan helps members use recommended and safe prescription medications
New 2017 ratings are expected to come out in October. You can find out more about our Star Rating and other measures including quality and member satisfaction ratings from The Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey results at NetworkHealthMedicare.com/Why-Network-Health/Top-Coverage.php. You can also request a printed copy of these ratings by calling a member of our health care concierge team. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.
A Form Can Save You (And Your Loved Ones) Headaches D
id you know that HIPAA (Health Insurance Portability and Accountability Act) regulations prevent Network Health from talking to others about your health insurance coverage?
One of the main goals of the law is to protect the confidentiality and security of health care information. That is important to us, too, but we also want to provide the best possible customer and care management services. With a simple form, you can designate an authorized representative. This person could be a spouse, relative, friend, advocate, attorney, doctor or someone else. After it’s signed, both you and your authorized representative can call to discuss your coverage, plan information and NetworkHealthMedicare.com
even to file a complaint or appeal if it’s ever needed. By filling out an authorized representative form when it’s convenient, you can protect yourself and your loved ones from headaches later. This person can then assist with your health care or contact us if you’re ever unable to. If you would like to name an authorized representative, visit NetworkHealthMedicare.com. Click Member’s Corner, and select the Appointment of Representative Form. Simply complete this form and send it to Network Health, Attn: Medicare Advantage Plans, P.O. Box 120, Menasha, WI 54952. You can also request a printed copy by calling customer service. C oncierge | 15
wellness
Combatting Depression ealing with depression and mental health concerns can feel isolating, but if you’re living with these medical conditions, you’re not alone. According to the National Institute of Mental Health, approximately 14.8 million adults suffer from major depression. There’s a good chance you or someone you know is struggling, or has struggled, with depression at some point in their lives.
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Feelings of sadness and depression are normal, especially in reaction to a loss or changes in life. But when feelings of intense sadness, helplessness, hopelessness or worthlessness last for days or weeks, it’s time to talk to someone. This is especially true if these feelings keep you from your normal routine.
Doctors can be a great resource in treating depression, but first you have to recognize the symptoms. n n n n n n n n n n n
Insomnia, early morning wakefulness or excessive sleeping Difficulty concentrating, remembering details and making decisions Fatigue and decreased energy Feelings of guilt, worthlessness and/or helplessness Feelings of hopelessness and/or pessimism Irritability, restlessness Loss of interest in activities or hobbies once pleasurable Overeating or appetite loss Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment Persistent sad, anxious or “empty” feelings Thoughts of suicide or suicide attempts
As the days shorten this fall and the weather turns cold and dreary, be on the look out for signs of depression in yourself and those around you. Seasonal affective disorder is a very real thing, and other forms of depression can feel even more overwhelming when winter rolls around. If you or a loved one has symptoms of depression, talk to your doctor as soon as possible. There are many types of treatment depending on your situation, including medication, light therapy, talk therapy and others. The sooner treatment begins, the more effective it is and the sooner you or your loved one will feel better. 16 | C oncierge
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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. n 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. NetworkHealthMedicare.com
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wellness
Common Questions About the Flu Shot T
here’s a lot of great things about fall, but flu season isn’t one of them. Luckily, you can help protect yourself by getting your annual flu vaccine. Make sure you know the facts about the flu shot.
Who should get a flu shot?
According to the Centers for Disease Control and Prevention (CDC), anyone over the age of six months should get a 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 a vaccine experience no side effects.
Where can I get a flu shot?
If you are a Network PlatinumSelect (PPO), PlatinumPlus (PPO) (with or without pharmacy), PlatinumPremier (PPO) (with or without pharmacy) or NetworkCares (PPO SNP) member, make sure to attend one of our Member Appreciation Events in October. You can get your flu shot there at no cost. For NetworkPrime (MSA) members, the cost will be $31.30 and can be applied to your deductible. If you choose to get your flu vaccine during an appointment with your doctor, remember that anything else discussed with your doctor (other than the flu vaccine) can result in a charge unless it’s previously scheduled. This could mean you need to pay a copayment.
Your Primary Care Physician
If you’d like to select a primary care physician (PCP), please share this 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.
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JOIN US FOR NETWORK HEALTH’S MEMBER APPRECIATION EVENTS Thank you for choosing Network Health for your Medicare Advantage Plan. We’d like to show our appreciation by inviting you to a member-exclusive event. All events are 9 a.m. to 3 p.m. and include the following. Detailed benefits presentations at 9 a.m., 10:30 a.m., noon and 1:30 p.m. n Flu vaccinations available n Updates on our broad provider network n Fitness benefit updates n Face-to-face service with a health care concierge n One-on-one guidance from local independent agents n
Date Monday, October 3 Tuesday, October 4 Wednesday, October 5 Thursday, October 6 Friday, October 7 Monday, October 10 Tuesday, October 11 Wednesday, October 12 Thursday, October 13 Monday, October 17 Tuesday, October 18 Wednesday, October 19 Thursday, October 20 Monday, October 24 Tuesday, October 25 Wednesday, October 26 Thursday, October 27
Venue Liberty Hall Liberty Hall World War II Hall Waupaca Ale House Holiday Inn Manitowoc Boarders Inn Best Western Premier Waterfront & Conference Center Holiday Inn KI Convention Center Bond Community Center Blue Harbor Resort Quality Inn City Inn Holiday Inn Hotel and Convention Center Eagles Club Crystal Falls Banquet Facility Royal Ridges
Address 800 Eisenhower Dr. 800 Eisenhower Dr. 440 West Main St. 201 Foxfire Dr. 4601 Calumet Ave. W7393 River Bend Rd. 1 North Main St.
Kimberly Kimberly Wautoma Waupaca Manitowoc Shawano Oshkosh
625 West Rolling Meadow 333 Main St. 1201 Park Ave. 725 Blue Harbor Dr. 815 Park Ave. 689 Broadway St. 1001 Amber Ave.
Fond Du Lac Green Bay Oconto Sheboygan Beaver Dam Berlin Stevens Point
1041 E Chestnut St. 1500 Handschke Dr.
Chilton New London
1 Westgate Dr.
Ripon
RSVP today with two simple steps
1 Have your Network Health ID card handy.
City
2 Reserve your spot online or by phone.
Visit NetworkHealthMedicare.com/MemberEvents or call 888-879-8960. TTY users call 888-833-4271. A registration representative can assist you Monday–Friday, 8 a.m. to 8 p.m.
NetworkHealthMedicare.com
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Good News About Our Provider Network
We have good news to share about our vast provider network and ThedaCare. Keeping our members’ best interests at heart, we designed our 2017 Medicare Advantage Plans to continue to offer in- and out-of-network coverage. It’s your right, as a member of a PPO plan, to choose in-network or out-of-network doctors. This means you can select any doctor who accepts Medicare beneficiaries. And, you won’t pay more to do so. ThedaCare’s current contract with Network Health will end December 31, 2016. That means ThedaCare will be considered an out-of-network provider in 2017. However, if you use ThedaCare providers and you don’t want to make a change, you can continue to see those providers out-of-network in 2017 with any Network Health Medicare Advantage Plan. See below for how this works with each of our plans.
Your Network Health Medicare Plan Name
Type What Doctors You of Plan Can See With all of our PPO plans, Network PlatinumSelect PPO you can see in-network or Network PlatinumPlus out-of-network doctors. You Network PlatinumPlus Pharmacy have the right to choose Network PlatinumPremier any doctor that accepts Network PlatinumPremier Pharmacy Medicare beneficiaries
NetworkPrime
NetworkCares
MSA
PPO SNP
There is no such thing as in-network with an MSA plan. You have the right to choose any doctor that accepts Medicare beneficiaries You’ve always been able to see in-network or out-ofnetwork doctors without any additional cost, as long as the provider bills Medicare and Medicaid. This won’t change
Can I see ThedaCare providers? Yes, out-of-network
Yes, the same as you can today Yes, the same as you can today
What Will I Pay in 2017? For services you receive, you’ll pay the same in-network and out-of-network. For example, a primary care office visit will have the same copayment out-ofnetwork as it would in-network (See page 23 for copayments) All Medicare-covered services are billed at the Medicareapproved amount until you reach the deductible. You pay nothing after you reach your deductible As always, what you pay will depend on your level of Medicaid eligibility
OTHER COMMON QUESTIONS
Will my doctor know I have this type of plan?
Every time a provider sees a Network Health Medicare Advantage Plan member, the front of every member’s ID card clearly indicates for the provider what the plan is. Your Network Health ID card will state your plan name and the type of plan it is on the front.
But can ThedaCare refuse to see Network Health Medicare members?
No. If providers accept Medicare beneficiaries, they can’t discriminate and only accept certain Medicare beneficiaries. They must accept any Medicare beneficiary, regardless of the type of Medicare insurance plan you have. What you will pay for your care is determined by the type of plan and benefits you have (see page 23 for a comparison of our plans). 20 | C oncierge
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2017 Northeast Wisconsin Medicare Plan Choices and Benefits
“
Our nurses walk alongside individuals and try to bring them to a place where they can find better balance.
“
Rosemary Dvorachek, RN Care Management Manager at Network Health
NetworkHealthMedicare.com
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STEP 1
Know Your Needs
Everyone’s health care and insurance needs are different. To find the plan that fits you best, consider the following questions. n Are you eligible for a Medicare Advantage Plan? To qualify, you’ll need to live in the plan’s service area and have Medicare Parts A and B. Check out the map to see Network Health’s northeast Wisconsin service area.
n Do you take prescription medications? If yes, you’ll need a plan that includes drug coverage.
n Do you want health care concierge service? With Network Health, you have direct access to a team of concierge customer service professionals located right here in Wisconsin.
STEP 2
OCONTO SHAWANO PORTAGE WAUPACA
KEWAUNEE OUTAGAMIE
WINNEBAGO
BROWN
MANITOWOC
WAUSHARA CALUMET MARQUETTE GREEN FOND DU LAC LAKE SHEBOYGAN
DODGE
Do Your Research
Each health plan offers different coverage. When comparing health insurance, make sure to think about the following. n What is the maximum out-of-pocket? The maximum out-of-pocket is the yearly limit on your costs for medical services. This is one of the most important things to consider. To protect your pocketbook, make sure to pay attention to this amount. n What is the plan’s deductible? Some plans have a deductible, the amount you pay before the plan begins paying. In 2017, Network PlatinumSelect (PPO), Network PlatinumPlus (PPO) and Network PlatinumPremier (PPO) have a $0 medical deductible. n What doctors and hospitals can I go to? Network Health contracts with a vast system of in-network doctors, hospitals and facilities, and, in 2017, you will pay the same costs for both in- and out-of-network providers. With a PPO plan, you have the right to choose in-network or out-of-network doctors. This means you can select any doctor who accepts Medicare beneficiaries. n Are my drugs covered? Before choosing a plan, make sure to review the list of covered drugs (called a formulary). This will help you understand what your prescription medications will cost. Visit NetworkHealthMedicare.com and click Look Up Medications to search the most up-to-date list. Or, call us for a printed copy.
Health insurance can be intimidating. At Network Health, we’re here to help.
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A QUICK SUMMARY
Network PlatinumSelect
Network PlatinumPlus Network PlatinumPlus (includes drug coverage) Pharmacy
Network PlatinumPremier Network PlatinumPremier Pharmacy
YOU PAY THE SAME IN- AND OUT-OF-NETWORK Premium
$0 per month (Includes drug coverage) Maximum Out-of-Pocket $5,900 per year combined Primary Care Office Visit $15 per visit Specialist Visit $50 per visit Urgent Care $30 copayment Hospital Stays $395 copayment for days 1-4. You pay nothing for days 5 and beyond Emergency Room $75 per visit Ambulance $275 copayment Outpatient Services $395 copayment per visit Annual Wellness Visit $0 copayment with Lab Tests All Medicare-covered preventive Preventive Services services at $0 ® SilverSneakers $0
$85 per month With drug coverage: $115 per month $3,400 per year combined $15 per visit $40 per visit $15 copayment $175 copayment for days 1-20. You pay nothing for days 21 and beyond $75 per visit $250 copayment 20% coinsurance per visit $0 copayment
$195 per month With drug coverage: $288 per month $3,400 per year combined $0 per visit $10 per visit $0 per visit $50 copayment for days 1-5. You pay nothing for days 6 and beyond $75 per visit $0 copayment $0 per visit $0 copayment
All Medicare-covered preventive services at $0 $0
All Medicare-covered preventive services at $0 $0
Network PlatinumSelect (PPO) (includes drug coverage) This plan has a $0 monthly premium and includes medical and prescription drug coverage. It can be a good a match if you don’t use a lot of health care services and would rather pay copayments instead of a monthly premium. Network PlatinumPlus (PPO) or Network PlatinumPlus Pharmacy (PPO)
This plan offers low copayments. It has great medical coverage and is available with prescription drug coverage to help you pay for your medications. If you’re looking for a plan with comprehensive coverage at an affordable price, this plan may be a good fit for you.
Network PlatinumPremier (PPO) or Network PlatinumPremier Pharmacy (PPO)
If you’d rather not pay copayments when you use health care services, this plan provides that option. You’ll pay more for your monthly premium, but then you’ll pay $0 for most services when you use them. Drug coverage can be included, too. If you don’t like having a copayment every time you visit the doctor, or if you go to the doctor a lot and need care often, you might want this plan.
The Benefits of Our PPO Plans n With a PPO plan, you have the right to choose in-network or out-of-network doctors n In 2017, you’ll pay the same costs in- and out-of-network n No referrals needed NetworkHealthMedicare.com
WHAT’S THAT?
IN-NETWORK
Doctors, hospitals, pharmacies and other health care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price.
OUT-OF-NETWORK
Doctors, pharmacies or health care facilities that aren’t part of your plan.
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NetworkPrime (MSA) NetworkPrime is a Medicare Medical Savings Account (MSA) plan. Here’s how it works.
Medicare MSA Plans Have Two Parts This is a another Medicare Advantage Plan which covers your hospital and medical care (known as Medicare Parts A and B). Once you’ve paid a certain amount for health care (called the deductible), the plan begins paying.
High-Deductible Health Plan
NetworkPrime has a $5,000 deductible and a $0 monthly premium.
Medical Savings Account
This is a special savings account used for health care costs. Once a year, Network Health deposits money into your account, and you can use this money to pay for health care before you meet the deductible.
NetworkPrime deposits $2,000 into this account once a year.
NetworkPrime $0 $5,000 You pay nothing for Medicare-covered services after you meet your deductible. This amount is prorated based on the month you enroll. Network Health will deposit $2,000 into your account prorated based on when Annual Deposit from you enroll. If you disenroll for any reason during 2017, you’ll be asked to pay Network Health back a prorated amount based on the date you disenroll. Services (like hospital stays, All Medicare-covered services are billed at the Medicare-approved amount until doctor visits and emergency you reach the deductible. You pay nothing after you reach your deductible. room visits) BENEFIT Premium Deductible
WHAT’S THAT? MEDICARE MSA PLAN - A special type of Medicare Advantage Plan that combines a
high-deductible health insurance plan with a medical savings account. MSA plans are offered by private companies like Network Health and work with Medicare to provide your coverage. You can use the medical savings account to pay for health care services, while the high-deductible plan limits your out-of-pocket costs.
NetworkCares (PPO SNP)
Did you know we also offer a plan for Medicare members with special needs? If you receive both Medicare and Medicaid, you may be eligible. This plan includes medical and drug coverage, plus eye and dental benefits and your own health care team. To learn more, call 800-983-7587 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m. 24 | C oncierge
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COST FOR A ONE-MONTH SUPPLY OF DRUGS You could save even more with a 90-day supply. INITIAL COVERAGE
Network PlatinumSelect Network PlatinumPlus Pharmacy Network PlatinumPremier Pharmacy
When your coverage starts, you pay a deductible and copayments until total drug costs (what you and Network Health pay) reach $3,700. $260 drug deductible for tiers 3, 4 and 5 Preferred Pharmacy $2 for Tier 1 $8 for Tier 2 $44 for Tier 3 $85 for Tier 4
Standard Pharmacy $4 for Tier 1 $13 for Tier 2 $47 for Tier 3 $90 for Tier 4
COVERAGE GAP
You enter the coverage gap when total drug costs reach $3,700. You pay 51% and Network Health pays 49% for generic drugs. For brand name drugs, you pay 40%, Network Health pays 10% and the drug company pays 50%.
CATASTROPHIC COVERAGE
You enter catastrophic coverage when what you pay reaches $4,950. You pay the greater of $3.30 or 5% of the cost for generic drugs and $8.25 or 5% of the cost for brand name drugs.
27% for Tier 5
WHAT’S THAT? NETWORK PHARMACIES - We have contracts with pharmacies to provide you prescription drugs. That
means you must use these network pharmacies for your drugs to be covered. Network pharmacies are broken into two groups—preferred and standard (non-preferred). You will pay less by using preferred pharmacies. See our Pharmacy Directory for a list, or click Find a Pharmacy on our website at NetworkHealthMedicare.com.
STEP 3
Make Your Choice
If you are happy with your current plan, do nothing. You will be automatically enrolled. n If you want to change plans, complete a change form. You can do this with a health care concierge, a member of our sales team or your agent. n If you are new to Network Health, you can enroll online at NetworkHealthMedicare.com, in-person at our Menasha office or through a licensed, local agent.
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PPO MEMBER EXTRAS SILVERSNEAKERS® FITNESS
Improve your health and live the life you want with SilverSneakers® Fitness. The program is included in your Network Health Medicare Advantage PPO Plan benefits and gives you membership at 13,000+ gyms nationwide. A program designed for all fitness levels and abilities, you’ll find the fitness support you need. Visit SilverSneakers.com to find a location near you.
HEARING AID DISCOUNT PROGRAM
For 2017, Network Health will offer a hearing aid discount program with Simpli Hearing, LLC, and Widex Hearing Instruments. Through this discount program, you can save on three levels of quality hearing instruments through participating audiology providers. The discount includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance.
COVERAGE THAT TRAVELS WITH YOU
If you like to travel to visit family and friends, or head south for the winter, you can relax knowing you’re still covered when you’re away from home. n When you’re outside Wisconsin, anywhere in the U.S., you can get care at the same cost you would at home.
In-network when you travel
SUPPORT TO GET AND STAY HEALTHY
If you have certain health conditions, you’ll have access to a team of registered nurses to help you manage your care. They can assist you with the following. n Help you monitor your disease and offer opportunities to successfully manage your health n Support communication between you and your doctor n Educational workshops, like Healthy Living with Diabetes, Living Well with Chronic Conditions and Stepping On (a falls prevention program) n Promote healthy lifestyle behaviors such as exercise and eating right n Home telemonitoring and home visit program for members who qualify n With your permission, work with a caregiver or family member to educate them about your condition
HEALTH CARE CONCIERGE SERVICE
Dealing with health insurance can be stressful and confusing. So, we provide friendly, personal service to every one of our members. These caring professionals help with any concerns you may have and get your questions answered. Our health care concierges are just a phone call away, and all customer service calls are answered right here in Wisconsin.
If you don’t understand something, it’s our job to make it easier. Call 800-378-5234 today. We’re available Monday–Friday, 8 a.m. to 8 p.m. From October 1–February 14, we’re here every day, 8 a.m. to 8 p.m. 26 | C oncierge
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EXPANDING INTO SOUTHEAST WISCONSIN
DER E
PPO
YOUR PLAN | YOUR PROVIDER | YOUR CHOICE
Network Health is growing and is now available to your friends and family in southeast Wisconsin. Co-owned by Froedtert Health and Ministry Health Care, we understand the importance of quality health care, and we believe it should be convenient, wherever you are. n See any provider who accepts Medicare beneficiaries n Coverage starting at $0 per month n Customer service that’s person-to-person n SilverSneakers® Fitness benefit n Coverage that travels with you
Explore your options with Network Health 800-983-7587 • TTY 800-947-3529 • NetworkHealthMedicare.com Out-of-network/non-contracted providers are under no obligation to treat Network Health Medicare Advantage Plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Nondiscrimination Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Multi-language Interpreter Services If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-378-5234. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-378-5234. Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 800-378-5234. NetworkHealthMedicare.com
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1570 Midway Pl. Menasha, WI 54952 Health and Wellness or Prevention Information
Meet Stacy Schwandner Each issue, we’ll feature a Network Health associate who works with Medicare members like you.
What’s your role at Network Health? I’m the manager of individual customer service at Network Health, and that means I oversee all things customer service for our Medicare members. I work with a talented team of health care concierges who put members first to provide exceptional service.
to be treated. Many of the questions they’re asked are similar, and it would be easy for their responses to become robotic. When I hear their calls, I’m proud you can’t hear the repetition in their voices. They know, for you, the question is the most important question you have for us, and you deserve the best.
How do you see customer service evolving at Network Health? When call volumes are high, the wait can be frustrating. We want to help you as quickly and thoroughly as possible. Next year, we’ll be exploring ways to improve wait times and the overall phone experience. One way is by giving you access to a full team of health care concierges—not just one person. Of course, if you’re working through an issue or following up on a question, you’ll still be able to reach that individual concierge directly through their own extension.
What is one thing you wish every member knew about Network Health? I wish that our members could see firsthand how our mission and values shape our decisions. When we factor in the numbers, our members’ perspectives, our value of service excellence and our mission to improve the life, health and wellness of those we serve, we come up with solutions that are truly in the best interests of our members.
What’s the best thing about your team? I love how much my team cares about our members as individuals. Our health care concierges treat members the way they want
What is one interesting fact about you? I’m “the voice” of Network Health. When you call our Medicare customer service line, and you hear a recorded welcome message, that’s not just a random voice. That’s me on the other end of the line. Now, you can have a face to go with the voice when you call.
Network Health Medicare Advantage plans include MSA and PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change January 1 of each year. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium. MSA plans combine a high deductible Medicare Advantage plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins. Medicare MSA plans don’t cover prescription drugs. If you join a Medicare MSA plan, you can also join any separate Medicare Prescription Drug plan. There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary. Contact the plan at 800-378-5234 (TTY 800-947-3529) for additional information.