L I F E , H E A LT H & W E L L N E S S
FA L L 2 01 8
Impacting Lives, One Prescription at a Time Read about how Ellen saved $77 per month by discussing her medications with a Network Health pharmacist
PAGE 5
Why Is It Important to Get Your Flu Shot?
PAGE 9
Myth Busters ... Brand Name Drugs vs. Generic Drugs
BACK COVER
Your New Member Portal
A PUBLICATION OF
Exclusive Reduced Rates for Network Health Medicare Advantage Plan Members For ticket information, visit networkhealth.com/offers Fox Cities Performing Arts Center - Appleton, Wisconsin FIDDLER ON THE ROOF – Dec. 2 at 1 p.m. Tickets on sale now. Offer expires Nov. 12, 2018. Subject to availability. Marcus Center - Milwaukee, Wisconsin HOW THE GRINCH STOLE CHRISTMAS – Nov. 23 at 2 p.m. and Nov. 24 at 5 p.m. Priority Seating - Tickets on sale now. Offer expires Nov. 18, 2018. Subject to availability.
THE PHANTOM OF THE OPERA, ANDREW LLOYD WEBBER’S NORTH AMERICAN TOUR – March 7 at 2 p.m. and March 17 at 6:30 p.m.
Priority Seating – Tickets on sale now. Offer expires March 1, 2019. Subject to availability. C
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4 Partnership Spotlight
13 What Is Medication Therapy Management?
4 Join Our Member Advisory Council
14 Take Control of Your Health with Our Help
5 Why Is It Important to Get Your Flu Shot?
15 Provider Profile – Dr. Arvind Ahuja, Froedtert South
6 Three Best Exercises for Balance and Stability
10
3 Letter from the President and CEO 4 An Interactive Experience
15 Breaking Down Obstacles to Care
7 How Prior Authorizations Impact Your Care
16 The Service You Deserve
8 The Silent Disease—Osteoporosis
18 Tips to Avoid Medicare Fraud
9 Myth Busters ... Brand Name Drugs vs. Generic Drugs
18 Know Your Member Rights and Responsibilities
10 Understanding Your 2019 NetworkPrime Benefits
19 Evaluating New Technologies
FEATURE 11 Impacting Lives, One Prescription at a Time
BACK COVER You Gave Us Feedback. We Listened.
H1181_1550-02a_0918_C EDITORIAL STAFF President and CEO Coreen Dicus-Johnson Chief Administrative Officer Penny Ransom Marketing Coordinator Romi Norton Lead Designer Debra Sutton
ASK NETWORK HEALTH If you have questions about anything you read in this issue of Concierge, call customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, 8 a.m. to 8 p.m. You can also learn more at networkhealth.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. © 2018 Network Health Insurance Corporation. No portion of this newsletter may be reproduced without written permission from Network Health Insurance Corporation.
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. 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 (TTY 800-947-3529). 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 (TTY 800-947-3529). 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 (TTY 800-947-3529). 2 | C oncierge
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life. health. wellness.
Letter from the President and CEO
T
hank you for being a Network Health Medicare member. To ensure you are using the full array of benefits Network Health offers, this edition of Concierge is filled with essential information to guide you in your wellness experience. One of the key features impacting many of you is our pharmacy department and the medication therapy management program. We have a tremendous team of clinical pharmacists here to help you. They can work closely with your personal doctor and your local pharmacist to make sure you are taking the right medications to benefit your personal health and your pocketbook. Some members automatically qualify for a medication review. For other members, the pharmacy team can provide personalized assistance to you as well—all you need to do is ask. Sometimes taking the right medications can make the difference in experiencing fewer side effects, taking less medication overall and better yet—saving money. I encourage you to take advantage of this service offered by Network Health. Best regards,
Coreen Dicus-Johnson President and Chief Executive Officer
See page 11 for a member’s story about her savings. networkhealth.com
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life. health. wellness.
An Interactive Experience Why are there Emmi icons featured throughout this issue of Concierge? By visiting the links provided, or viewing Concierge online, you can view interactive videos on a variety of health topics. Each icon takes you to free, animated, online programs provided by Emmi®. Watch them on your computer, smartphone or tablet as many times as you like.
PARTNERSHIP SPOTLIGHT N
etwork Health assures the highest standards of quality, service and affordability for you. To ensure you receive the best and most appropriate care possible at the most appropriate time, we partner with eviCore HealthCare and other support providers with expert consultation and tools.
Here are some services that require prior authorization through eviCore HealthCare. Interventional pain management n Large joint procedures of the hip, knee and shoulder n Spinal procedures n Radiation oncology therapy services n Medical oncology services n Molecular genetic lab testing n All ambulatory cardiac diagnostics including diagnostic cardiac catheterizations, nuclear cardiology scans, stress echocardiograms, transesophageal echocardiograms n
If you receive care at an in-network provider, there’s nothing you need to do to ensure authorization requirements are met. Your doctor will request the authorization for your care. See page seven for more information on prior authorizations.
Join Our Member Advisory Council
We appreciate your experience as a Medicare member and value your input. We invite you to serve on our member advisory council. Our council helps shape the decisions of Network Health, so we continue to offer the quality service and plans you need and want. For more information contact customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m. 4 | C oncierge
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Why Is It Important to Get Your Flu Shot? By Michele Eggers, coordinator quality health, with Network Health
People age 65 and older are at greater risk of serious complications from the flu due to weakening immune systems. The Centers for Disease Control and Prevention estimates as many as 85 percent of flu-related deaths and 70 percent of flurelated hospitalizations occur in people age 65 or older.
Most people who get the flu will recover within two weeks, but others may develop serious complications, including the following.
Pneumonia Respiratory failure Kidney failure
Inflammation of the heart, brain or muscle tissue Worsening of chronic medical problems such as asthma and heart disease
The best way to protect yourself is to get an annual flu shot. Each year, flu vaccines are developed to protect against current viruses. It takes approximately two weeks to build up immunity, which then lasts about 12 months. Get your flu shot as early as possible to ensure you’re protected from the beginning through the end of flu season. Although there are vaccines developed for high-risk individuals, most people should not delay vaccination while waiting for a specific vaccine to become available unless recommended by your doctor or pharmacist.
People age 65 and olde r should not get the following.
Nasal spray flu vaccin e (only approved for people 2-49 year s old) Intradermal flu shot (only approved for people 18-64 years old) Jet injector flu vaccin e (only approved for people 18-64 ye ars old)
Protect yourself this season with these additional precautions.
Cover coughs, wash hands often and avoid people who are sick. Seek medical advice if you develop flu-like symptoms (such as fever, cough, sore throat, body aches, chills or fatigue). A medical evaluation or treatment with antiviral drugs may be necessary for those at higher risk of complications. Antivirals are most effective if started within two days of developing illness. Stay up-to-date with pneumonia vaccinations. Getting a flu shot is easier than suffering through flu symptoms and can help you stay healthy year-round.
Visit www.goemmi.com/NHP-FLU for free, interactive programs on the flu vaccine. networkhealth.com
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3
Best Exercises for Balance and Stability By Aleisha K. Fetters with SilverSneakers®
W
hen we’re young, we take staying upright for granted. We don’t really worry about falling—it might not even cross our minds.
Over the years, things change. The body’s systems that detect gravity, identify exact body positioning at any moment, determine what you need to do to stay upright and promote balance and stability become less effective, says Caroline DeGroot, M.P.T., a physical therapist at Athletico. It’s easy to see why falls are the number one cause of injuries and death among older Americans. In fact, according to a report from the Centers for Disease Control and Prevention (CDC), an older adult falls every second of each day in the United States. If you’ve fallen, tell your personal doctor. Half of older adults who fall don’t tell their doctor—which means injuries can go untreated and a balance problem could get worse. Follow your personal doctor’s instructions for any treatment or physical therapy and ask how you can exercise safely. It’s never too early to start thinking about improving your balance and preventing falls. Below, DeGroot shares her favorite exercises for better stability. Perform these bodyweight moves as often as possible—when you’re standing at the kitchen counter or waiting in line while running errands. With each exercise, hold onto the wall or a sturdy piece of furniture for balance. As you get stronger, you can try without holding onto anything. 1. Foot Taps Stand tall with your feet hip-width apart in front of a step (the bottom step of a staircase will work) or low piece of furniture. From here, slowly raise one foot to tap the step in front of you, and then slowly return it to the floor. Perform 15 to 20 taps, then repeat on the opposite leg. 2. Head Rotations Stand tall with your feet hip-width apart. From here, slowly move your head from side to side then up and down while keeping your body as still as possible. Do this for 30 seconds and repeat. If you get dizzy, pause and move your head more slowly. If you’re still dizzy, stop. 3. Standing Marches Stand tall with your feet hip-width apart. From here, lift one knee until your thigh is parallel to the floor (or as close to parallel as you can get) while keeping your torso straight and avoiding any leaning. Pause, then slowly return your foot to the floor. Perform 20 marches, alternating legs with each march. 6 | C oncierge
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What else can you do?
Tell your personal doctor if you have fallen recently, feel unsteady on your feet or feel lightheaded or dizzy often.
Tell your personal doctor about all the medications you take, including prescription drugs, over-the-counter medications and supplements. Your doctor will check if any medications increase your risk of falling. As always, do not stop or change medications unless instructed by your doctor. Work with your personal doctor to manage any chronic conditions like diabetes or arthritis. The healthier you are overall, the lower your risk of falling. Get your eyes checked once a year. Vision problems can increase your risk of falling. Eat bone-strengthening foods with plenty of calcium and vitamin D. Practice balance exercises regularly. If you prefer group exercise, check out SilverSneakers Stability or tai chi classes. Keep your floors free of clutter. Secure or remove loose rugs and make sure there is plenty of light. Don’t be afraid to ask family or friends for help with these tasks.
How Prior Authorizations Impact Your Care
H
ave you ever been asked to submit a prior authorization before care is covered by your health insurance? Did you wonder why? It’s a common question, and we’re here to give you the answer.
What is a prior authorization? Certain prescriptions,
procedures and equipment require approval from a Medicare plan before they are filled or completed to be sure that they are covered by the plan.
Why is this important to you? Fraud, waste and abuse can
exist in the medical profession and prior authorizations help to reduce those issues and create a much better experience for you while controlling overall health care costs.
How is the review conducted? Medical experts review
records and documentation to decide the best course of action.
networkhealth.com
Example. You’re asked to submit a prior authorization for rotator cuff surgery. The medical experts at the insurance company review the records and x-rays and deny the surgery. Instead, they recommend you have physical therapy because surgery may not be necessary. Although upset with the insurance company at first, you participate in physical therapy and never need to have the surgery. While surgery may have been successful, the physical therapy was much easier reducing recovery time and overall costs.
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The Silent Disease—Osteoporosis By Carol Hirn, RN/BSN with Network Health
O
steoporosis may affect more than half the population in the United States at some time in their lives. You may hear it referred to as “brittle bones” or “weak bones.” Osteoporosis is also often called the “silent disease” because people usually have no symptoms and may not know they have osteoporosis. The weakening of their bones, however, significantly increases their risk for an injury or fall causing a broken bone.
Both men and women can have osteoporosis, but here are some factors that put you at higher risk.
GENDER
AGE
It’s more common in women.
BODY SIZE
The older you are, the Small, thin women higher your risk. are at greater risk.
ETHNICITY
FAMILY HISTORY
White and Asian women are at highest risk.
Osteoporosis tends to run in families.
A healthy lifestyle can help decrease your risk
Eat a diet rich in calcium and vitamin D. Low fat milk, yogurt and cheese as well as foods with added calcium—orange juice, cereals and breads—are all good sources. Ask your personal doctor if a Vitamin D or calcium supplement is right for you.
Exercise, especially weight bearing exercise such as walking, hiking, dancing and lifting weights, can all help increase bone strength.
Limit your alcohol intake.
Don’t smoke, or take steps to quit smoking.
To help minimize the effects of falls or fractures, your doctor may recommend a bone density test or medications to help protect your bone strength.
WHAT’S THAT? A BONE DENSITY TEST measures the amount of bone mineral in your bone tissue, determining the density of bones and the chances of the bone being broken. A bone density test is recommended for most women age 65 or older, or younger for those at risk and/or those who have had a recent fracture.
Visit www.goemmi.com/NHP-BONE for more information on osteoporosis. 88 || C Concierge oncierge
Networkhealth.com networkhealth.com
h t My rs … te s u B
d
an me a n nd ay. t bra xist tod u o e ab ths ations y m ic y Man ric med e gen
Brand Name Drugs
vs.
Generic
Drugs
By Anna Peterson Sanders and Gary Melis, pharmacists with Network Health
Myths
Brand name is best.
Generics are less effective.
Brands cost more, but are worth it because they work better.
Generics hit the market with little oversight.
Brands are safer.
T
he truth is, the U.S. Food and Drug Administration (FDA) has a very extensive process that generic manufacturers must undergo before approval. Here’s a summary of the FDA’s process.
Generic versions must have the same active ingredients, effectiveness, quality, safety, strength and benefits as the brand version. • The active ingredient is the chemical portion of the medication that allows it to do what it’s supposed to. • Inactive ingredients are also present in medications and do not provide benefit or harm. They are used to create the medication to help in different ways including binding, dissolving, stability and taste. The FDA requires that inactive ingredients are determined to be safe. The manufacturer must be able to make the medication correctly and consistently, ensuring it doesn’t break down over time and that the container used to sell the medication is appropriate. In addition, a generic medication cannot be approved until the patent on the brand has expired. • Patents allow exclusive marketing rights for a certain period of time, giving manufacturers financial incentive to invest in drug development. Without competition, this gives companies an opportunity to price their drug much higher than will later be seen with its generic counterparts, helping them recoup drug development costs. • Generics are less expensive because they do not need to repeat the studies that the brand must undergo. Additionally, multiple companies often begin making the generic version, providing market competition. This results in a reduction in cost, which is usually about 85 percent less than the brand name. So, while brand name medications cost more, it doesn’t mean they are better than generics. Just as brand name medications undergo an FDA review, generics also go through an FDA review process to be deemed equivalent to the brand version. Be assured that generics are just as safe and effective as brands, but have the added advantage of being much kinder to your wallet.
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life. health. wellness.
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
Medical Savings Account
NetworkPrime has a $5,100 deductible and a $0 monthly premium.
This is a special savings account used for health care costs. Once a year, Medicare deposits money into your account, and you can use this money to pay for health care before you meet the deductible. Medicare deposits $1,500 into this account once a year.
BENEFIT
NetworkPrime
Premium Deductible
$0 $5,100
Annual Deposit from Network Health
Medicare will deposit $1,500 into your account prorated based on when you enroll. See the chart on the back based on your plan effective date. If you disenroll for any reason during 2019, you’ll be asked to pay back a prorated amount based on the date you disenroll.
Services (like hospital stays, doctor visits and emergency room visits)
All Medicare-covered services are billed at the Medicare-approved amount until you reach the deductible. You pay nothing after you reach your deductible.
WHAT’S THAT?
MEDICARE MSA PLAN
This is 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. 10 | C oncierge
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COVER STORY
IMPACTING LIVES One Prescription at a Time
By Romi Norton, Photography by Beth DesJardin, Trove Photography
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COVER STORY
H
ave you ever been at the pharmacy checkout counter and wondered how the total price got so high?
Prescription medications can be expensive, but they are a critical part of maintaining or improving your health. You know they must be taken as prescribed to stay healthy. Every month, you dutifully fill your prescriptions, but in the back of your mind, you think about the growing expense. You may even discuss other available options with your personal doctor and occasionally you may get some financial relief. We recently spoke with Network Health Medicare Advantage members Ellen and Art S. who had a similar experience. Ellen had been prescribed Symbicort® which resulted in an out-of-pocket expense of $110 per month for one prescription. At the time, she wasn’t sure that any other options were available. That’s what her personal doctor had prescribed and that’s what she was going to take. Fortunately for Ellen, she participates in the Network Health Breathe at Ease program which connects her with a respiratory therapist. She receives a monthly phone call from respiratory therapist Robyn West to see how she is doing. In fact, it was Robyn who recommended Ellen reach out to Network Health Pharmacist Gary Melis to determine if there were any options available for a lowercost inhaler. “Robyn thought that something could be done about the prescription, that there might be another option that would be comparable and less costly. I think it’s great that she was advocating for me, I really appreciate Robyn’s help. She’s very encouraging and listens. I like that somebody is keeping track of how I am feeling,” Ellen said.
She continued, “I had a phone call with Gary to talk about the options. It didn’t take long at all. He recommended fluticasone/salmeterol which is like a powder inhaler. He said it would be less expensive monthly and provide the same relief.” Ellen ended up saving $77 per month. Most members may not realize that the Network Health pharmacists are available to offer this type of assistance. The pharmacists can provide individual medication review options like Ellen’s experience. Network Health also offers a program called Medication Therapy Management (MTM) which takes a deeper dive and reviews all the medications a member takes, including over-the-counter items and vitamins. When Ellen was asked if she knew about the pharmacy programs available at Network Health before Robyn mentioned it, she said, “Someone called me at one time. I thought, I don’t want my insurance interfering with what I was doing. I didn’t want them to tell me what I could do and couldn’t do. I did not understand at the time that they would be there to help me with whatever I needed.” “Gary was very helpful. He got things straightened out and recommended this new prescription. He said if I was willing to try it, that would be a good thing.” When asked her opinion about the Network Health pharmacy program, Ellen said, “If you have a chance to work with them, go ahead and do it. They may be able to help you save money and get yourself organized.” Ellen and Art look forward to doing fun things with the additional monthly savings. “We enjoy special Friday night dinners out with friends.”
Meet Gary Melis, Registered Pharmacist Gary Melis is a clinical pharmacist who has been with Network Health for seven years. Gary is one of the three pharmacists that manage the Medication Therapy Management (MTM) program. He reaches out to Network Health members directly to assist with medication reviews. With retail pharmacy and long-term care experience, Gary brings a wealth of knowledge to our members. He also volunteered as a pharmacy instructor at Mosaic Family Health in Appleton. 12 | C oncierge
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If you have a chance to work with them, go ahead and do it. They may be able to help you save money and get yourself organized. Ellen S., Network Health Medicare member
What Is Medication Therapy Management? Members that meet eligibility requirements are automatically enrolled in the MTM program and will receive the following, at no additional cost. An introductory letter explaining how to get started. An offer to participate in an annual comprehensive medication review. This review will ensure you get the best results from your medicines from the comfort of your home. A follow-up letter that outlines the review and suggests next steps. This is a great tool to share with your personal doctor and other health care providers.
To meet eligibility requirements, members must meet the following the criteria.
1.
Have at least three of the following long-term (chronic) medical conditions: asthma, chronic heart failure, chronic obstructive pulmonary disease (COPD), depression, diabetes, end stage renal disease, high blood fat levels, high blood pressure or osteoporosis.
2. 3.
Take seven or more daily medicines covered by Medicare Part D.
Part D covered medications cost more than the CMS specified annual cost threshold. For 2019, that amount is $3,820. If you don’t meet the eligibility requirements but are still interested in reviewing your medications, call a health care concierge at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m. to schedule time to speak with a pharmacist. As a Network Health Medicare member, this service is available at no cost to you.
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Take Control of Your Health
with Our Help
D
id you know Network Health offers member wellness, condition management and care management services at no cost to you? Whether you’re dealing with an unexpected health issue, a complex diagnosis, a chronic disease or just need a little help maintaining your health, care management services can help. Managing your health conditions can increase your sense of well-being and put you in control of your health.
Our member wellness coordinators work with you to meet your goals with the following. Nutrition Weight loss or management Physical activity Stress management Blood pressure Blood cholesterol Blood sugar Sleep concerns Quitting tobacco For our members with diabetes, heart disease, heart failure, chronic obstructive pulmonary disease (COPD) or depression, our condition management team can provide educational resources specific to your diagnosis. Care management begins with a one-on-one conversation between you and one of our care managers. If you choose to participate, they will work with you to help you manage your health conditions and meet your health goals. After learning more about you and your health concerns, your care manager can assist you with the following. Answering any questions you may have Reviewing your medications and treatment plans Informing you about the signs that your health condition is worsening and when to act, including when you should contact your personal doctor Working with your health care providers to ensure they are aware of changes in your health Ensuring you and/or caregivers feel included in your health care decisions Helping set health care goals to maintain or improve your health Helping you with coordination of care with providers and community services
To benefit from member wellness or care management support, or find out more about our programs, call 866-709-0019 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 5 p.m. You may leave a message 24 hours a day, seven days a week. Or get more information on our programs at networkhealth.com, select Medicare Plans and select Wellness Programs. Participation is optional and you may opt out of care management at any time by calling the health care concierge team at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m. 14 | C oncierge
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Provider Profile –
Dr. Arvind Ahuja, Froedtert South
P
atrick Berger never thought much about brain health until his mother died from a ruptured brain aneurysm in 2002. Her surgeon advised Patrick to get himself checked due to the strong hereditary link of the condition. As it turns out, that aneurysm screening saved Patrick’s life; it showed that he had a 4-millimeter aneurysm.
I really believe that if I didn’t find out, by this time, I would not be here, Berger said. Dr. Arvind Ahuja, a neurosurgeon affiliated with Froedtert South, performed a craniotomy to eliminate Patrick’s aneurysm. An aneurysm is thinning of the wall of a blood vessel, which may result in the ballooning of that area. If it ruptures, the person typically feels the worst headache of his or her life. “One-third die immediately; one-third die in the hospital; one-third survive,” said Ahuja.
Dr. Arvind Ahuja
Approximately one in every 50 people will develop an aneurysm at some point in life. “They may not need treatment for them, but they may have them,” Ahuja said. “Smoking and high blood pressure are controllable risk factors,” Ahuja added. If you have a “first-degree relative” who has had an aneurysm your chances of developing one are double; with two family members, it’s quadruple. Dr. Ahuja is the only neurosurgeon in the Kenosha area experienced to perform both aneurysm repair procedures (clipping and coiling). “I was off work for eight weeks, then went back to work and everything was fine,” Patrick said. “I literally had no problems at all.”
WHAT’S THAT? A FIRST-DEGREE RELATIVE is considered a parent, sibling or child.
Breaking Down Obstacles to Care
Treatment 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. Beliefs and concerns about your condition and treatment Access, transportation and financial barriers to obtaining treatment Cultural, religious and ethnic beliefs that conflict with treatment
Call 866-709-0019 (TTY 800-947-3529) to speak with a nurse who can help ensure your treatment plan fits your life. networkhealth.com
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life. health. wellness.
The
ServiceYOU
DESERVE t Network Health, we make every effort to ensure you’re receiving the service you need and deserve. 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, you have the right to file an appeal or grievance. We have a team of appeals and grievance specialists who will work with you throughout this process.
When do I file an appeal? You have the right to file an appeal if you do not agree with Network Health’s decisions about your health care. You can submit an appeal in writing within 60 calendar days from the date you receive the claim denial. Your written appeal should include your full name, member ID and information about what you are appealing. You may also include any comments, documents, records or other information you would like Network Health to consider in its review.
Examples of situations appropriate for an appeal include the following. Network Health will not approve care it should cover. Network Health is stopping care you still need. Network Health has denied payment for services or items you have received and you think they should be covered.
n n n
Who may file an appeal?
You or someone you name to act for you (called your representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor or someone else to act for you. To name your representative, visit networkhealth.com, select Medicare Plans, select 16 | C oncierge
Member Resources and select the Appointment of Representative form. Simply complete this form and send it as outlined in the Contact Information section.
What happens after I file an appeal? If you appeal, we will review our decision. If payment for any of your claims is still denied after our review, we will automatically forward your Part C appeal request to the Medicare 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 your Medicare Advantage organization. If you disagree with that decision, you will have further appeal rights and you’ll be notified of those appeal rights if this happens.
How are medication appeals handled?
Medication appeals are reviewed by a Network Health Pharmacist and Network Health Medical Director, as needed. The pharmacist communicates with the prescribing provider if additional information is needed or discusses alternative covered medications. Our pharmacists have a goal of addressing medication appeals within four hours and have been successful over 90 percent of the time. This means better customer service for both physicians and our members. networkhealth.com
When do I file a grievance?
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, our vendors or contracted providers provided services.
Examples of situations appropriate for a grievance include the following. n n n n
Difficulty getting through on the phone Concerns about the quality of care of services provided Interpersonal aspects of care (for example, rudeness of a provider or staff) Failure to respect your rights
Contact Information Appeals and Appointment of Representative Form Call: Health Care Concierge Team at 800-378-5234 (TTY 800-947-3529). Fax: 920-720-1832 Write: Network Health Attn: Medicare Advantage Plans P.O. Box 120 Menasha, WI 54952
networkhealth.com
You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event. See the Contact Information provided.
Grievance Call: Health Care Concierge Team at 800-378-5234 (TTY 800-947-3529) Fax: 920-720-1832 Write: Network Health Attn: Appeals and Grievances P.O. Box 120 Menasha, WI 54952
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Tips to Avoid Medicare Fraud
M
edicare fraud costs American taxpayers billions of dollars each year and results in higher medical costs for everyone. Network Health offers some tips to help you avoid Medicare fraud. Follow this guide to keep your information safe.
DO • • • • • •
Refuse and return medical supplies you didn’t order. Medicare doesn’t sell or mail supplies. If you receive unordered supplies, you may be the target of fraud. Let Network Health know the name of the company that sent the supplies. Keep accurate records of all your health care appointments. Read your explanation of benefits carefully and make sure all services listed are services you received. Always watch your credit card and bank statements for any improper billing activity or fraudulent withdrawals. Monitor your credit report regularly.
DON’T • • •
Don’t give your Social Security, Medicare, financial information, Network Health member ID number or credit card information to someone you don’t know. Only give your information to those who have provided you with a medical service. Don’t trust door-to-door salespeople or telemarketers selling health care services or durable medical equipment, like diabetic supplies or back braces. And, remember—free services do not require you to give out your plan or Medicare number. Never sign blank insurance claim forms.
What if I’m scammed? 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 a Medicare scam, we are here to assist you. Call a member of our health care concierge team or send an email to paymentintegrity@networkhealth.com. 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 (TTY 800-947-3529) and can be reached 24 hours a day, seven days a week.
Know Your Member Rights and Responsibilities Did you know you have rights and responsibilities as a Network Health Medicare member? To learn more about how we provide you with service that respects your rights, go to networkhealth.com, select Medicare Plans and select Member Resources. On this page you’ll find Member Rights and Responsibilities. You can also call customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m. to request this information.
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networkhealth.com
Evaluating New Technologies
Have you ever wondered why new benefits get added to your health plan? Why is something covered this year when it wasn’t covered last year?
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etwork Health evaluates new technology and new applications of existing technologies on a regular basis to ensure our members receive safe and effective treatment and care. We evaluate medical and behavioral health procedures, drugs and devices. We base our decisions on the following. Food & Drug Administration approval Scientific evidence Opinion of contracted providers Government regulatory agencies Manufacturer information Peer-reviewed articles Risk/benefit analysis Assessments performed by agencies specializing in technology
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New technologies are reviewed by our Medical Policy Committee (MPC), which is comprised of a group of participating physicians and Network Health employees. This group makes recommendations for inclusions as a covered benefit.
The following technologies have been reviewed over the past 12 months.
Technology Review
Outcome
3D mammography/a.k.a. breast tomosynthesis
MPC decided this technology is safe and effective; Network Health has removed this technology from our experimental, investigational and unproven review process.
OPTUNE Device (Tumor Treatment Fields therapy TTF)
MPC decided this technology remains experimental, investigational and unproven.
Epifix (skin substitute material)
MPC determined this to be safe and appropriate for diabetic foot ulcers and venous stasis ulcers, when applicable criteria are met. This has been added to our Skin Substitutes Medical policy.
Grafix (skin substitute material)
MPC determined this to be safe and appropriate for diabetic foot ulcers when applicable criteria are met. This has been added to our Skin Substitutes Medical policy.
If you have a question about a technology assessment, contact our care management department at 800-236-0208 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 5 p.m. networkhealth.com
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1570 Midway Pl. Menasha, WI 54952
PRESORT STD US POSTAGE PAID GREEN BAY, WI PERMIT NO. 1033
MSA
You Gave Us Feedback.
We Listened. Based on member testing and feedback, we’ve given our member portal a complete makeover to provide you an improved experience. In it, you’ll find content that’s unique to you. You’ll also find tools, tips and important information to help get the most out of your benefits. Plus, the new portal is mobile responsive, so you can access your plan information 24/7 from any device. Create your new account today at login.networkhealth.com. The first time you visit the new portal, you’ll need to create a new account. Whether or not you’ve accessed our old portal, you’ll still need to create a new account. Once signed in, you can get benefit information, find a doctor, view out-of-pocket expenses, reorder an ID card, access plan materials and more. You’ll also be able to select communication preferences, so you can choose to receive Explanation of Benefits statements by email instead of mail. Set up your new account now at login.networkhealth.com, so you’ll have easy access to everything you need to manage your plan. What Else Will You Find? • Benefits and coverage overview • Out-of-pocket expenses tracker • Claims detail and status • Explanation of benefits statements • Authorization information and status • Mobile access to order an ID card • Plan-related materials and forms • Secure messaging with our local customer service team • Ability to make a premium payment • Wellness tools
NetworkPrime is a MSA plan with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal.