BENEFIT
SUMMER 2017 | FI
FOR
HEALTHALLIANCE.ORG
EXPEDITION Healthcare Coverage Life gets hectic, and it’s easy to get lost in the healthcare confusion. When that happens, let For Your Benefit be your guide. It’s packed with tools and information to help you navigate your health plan. So lace up your hiking boots, grab your sunglasses and explore your coverage in this issue.
Metabolic Panel Coverage In June, some plans will begin covering all metabolic panels under the medical benefit. Previously, these plans covered some types of metabolic panels under the wellness benefit. This could affect your out-of-pocket costs for these services, depending on your plan. If you have questions about how this will affect your coverage, call the Customer Service number on the back of your ID card.
MAP COMPASS
CALCULATOR? Although the Treatment Cost Calculator doesn’t seem like a typical camping tool, it’s good to know your healthcare options in case something happens on your next big hike or in everyday life. The Treatment Cost Calculator is an online tool that helps you compare costs for healthcare services. You won’t need it every day, but it’s good to get familiar with it now so you can use it as a guide next time you’re planning to get care. Check it out today at YourHealthAlliance.org.
FEATURES • Search for a specific service or browse by health topics, outpatient or inpatient procedures, diagnostic tests and more. • Search results include an icon that tells you the type of service, like outpatient, inpatient, office visit, lab work or diagnostic. • Choose to see a low, likely or high cost estimate for a service based on your benefits. • Compare costs for providers near you who offer the service or get estimates for a specific provider.
Your plan may not include all providers in the Treatment Cost Calculator database. Once you receive your estimate, check YourHealthAlliance.org or call Customer Service to verify your provider network.
TAKE RALLY ON
YOUR NEXT Rally®, an easy-to-use digital health tool that comes with your plan, helps you reach your fitness goals whether you’re gearing up for your next hiking trip or just starting to work out. With personalized missions, group challenges, support and rewards, Rally helps you move more, sleep better, eat healthier and reduce stress. You’ll find plenty of missions to help you reach your goals. Try one of these next time you explore the great outdoors.
Run 30 minutes per day
Bike 20 minutes per day
Walk 10,000 steps per day Join Rally today at HealthAlliance.org/Rally.
If you don’t have internet access, health surveys, self-management tools and rewards are also available by mail or phone. To participate, call the Customer Service number on the back of your ID card.
Better Health in Your Hands Rally now offers an app that helps make it easier for you to improve and maintain your health. Download the Rally HealthSM app at the App StoreŽ (iOS) or Google Play (AndroidTM). Go to RallyHealth.com/HealthAllianceMobile and register using Rally mobile code: HealthAlliance Already on Rally? You’re all set. Download the app and log in.
Give a Gold Star Have you had a great experience with somebody at Health Alliance? If so, you can give that person a Gold Star as a special way to say thanks. We’ll share your story with that person and his or her manager and peers. And we might even use it in ongoing employee recognitions. You can thank someone today at HealthAlliance.org/GoldStar.
Building
Bridges TO COVER EXPENSES
It’s hard to predict all of your healthcare expenses, and when life throws a few rapids your way, it’s great to know you have a bridge to cover some of the costs.
if you reach your out-of-pocket maximum, the plan pays the rest of the way for that benefit period (as long as your expenses* are eligible for coverage).
For many services, you must reach your deductible before your plan starts paying a portion of your healthcare costs. But your plan covers many preventive services even before that.
You can see how close you are to meeting your deductible and reaching your out-of-pocket maximum at YourHealthAlliance.org.
Once you meet your deductible, your plan covers a portion of your expenses, and you bridge the gap together. And
Plans that offer out-of-network coverage have separate in- and out-of-network deductibles and in- and out-ofnetwork out-of-pocket maximums.
START Deductible
Set amount you pay before the plan starts helping pay for medical or pharmacy expenses. Some plans have separate medical and pharmacy deductibles.
Out-of-Pocket Maximum
Set amount you pay before the health plan pays 100 percent of eligible expenses* for the rest of the benefit period. (Once you meet it, you won’t pay copays or coinsurance, just your monthly premium or contribution for coverage.)
*Some expenses might not apply to the out-of-pocket maximum. Check your plan materials.
Fully Insured Essentials
Customer Service Is Here to Help Call 1-800-851-3379, TTY 711, Monday through Friday, 8 a.m. to 5 p.m. CT.
We can help you with questions about claims, coverage, appeals, pharmacy issues, preauthorization, utilization management and information about the doctors, clinics and hospitals we work with. After normal business hours, leave a message, and your call will be returned the next business day. Please note that all non-urgent review requests received after normal business hours will be recorded as being received the next business day. Please call Customer Service if any of your personal information has changed, including: • Name • Address • Phone number
Keep Your Member Materials Handy
To make the most of your benefits, read the plan materials you received when you first joined the plan. These materials are a convenient source for quick information about your coverage. If you need additional copies of your plan materials, please contact Customer Service or log in at YourHealthAlliance.org.
Find Answers Online*
Find convenient answers to your questions online anytime at HealthAlliance.org. It has information about your coverage and our processes, such as: • Member rights and responsibilities • Our most recent HEDIS® and CAHPS® scores • Rally® **, our health management tool • Medical and pharmaceutical management policies and procedures, including how we review new technology
• Number of dependents • Primary care physician, if applicable • Other insurance
Continued on next page
*If you don’t have Internet access, you can request printed copies of the materials on the Health Alliance website by calling Customer Service. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
• How to file a complaint or appeal, including your right to involve an external review organization • Which benefits and services are included and excluded from your coverage in and out of the service area • How to get emergency care, primary care, specialty care and behavioral health services during and after normal business hours in and out of service area • How to get information about in-network physicians and hospitals, including searching for providers Register and log in at YourHealthAlliance.org today to: • View eligibility • Check the status of a claim • Learn how to submit a claim • Order a new ID card • View the Drug Formulary, evaluate drug interactions and determine financial responsibility for prescriptions • View your deductible and find your copayments or coinsurance • Read the Health Alliance notices of privacy practices • View your plan materials Visit HealthAlliance.org, or sign up for a username and password by going to YourHealthAlliance.org and registering as a member. **If you don’t have internet access, health surveys, self management tools and rewards are also available by mail or phone. To participate, call the number on the back of your ID card.
We Speak Your Language
If you are more comfortable speaking a language other than English, try our telephone translation service, Language Line. We provide access to interpreters who speak 200 different languages. Simply call the Customer Service number listed on the back of your member ID card and tell them which language you speak. If you need documents translated into a different language, you may request them by calling 1-800-851-3379. Si usted necesita un interprete para traducir esta información, por favor llamar al teléfono gratis 1-800-851-3379 y pregunte por la “Language Line.” Si usted necesita documentos tradujeron a un idioma diferente, usted puede solicitar que llamando 1-800-851-3379.
Better Service, Better Care
Health Alliance Quality and Medical Management Departments continually strive to provide programs and tools to help members and providers promote healthy lifestyles. Our goals are to identify special needs of the populations we serve, establish clinical care and service standards for those populations based on industry standards, and measure performance outcomes while adhering to regulatory and plan requirements. After improvement opportunities are identified, we respond with appropriate interventions to improve care and service and then measure their effectiveness. Through regular monitoring and an annual evaluation, we continue to meet the goals we have set. To view our complete program, go to HealthAlliance.org/Why. Some examples of our initiatives include: Clinical Guidelines Health Alliance encourages contracted doctors to consult nationally recognized standards, called clinical guidelines,
when providing care to members. These evidence-based treatment suggestions have been developed to help doctors choose appropriate healthcare treatment for specific medical conditions. Doctors can review the guidelines on the Health Alliance website or contact the Quality and Medical Management Department at 1-800-851-3379, extension 8112, for a copy. NCQA® Accreditation We participate in the health plan accreditation program through the National Committee for Quality Assurance (NCQA). This ensures we meet a rigorous set of nationally recognized standards for quality and service to our members and providers. For more information, visit the NCQA website at NCQA.org. HEDIS® and CAHPS® Health Alliance participates in the annual Healthcare Effectiveness and Data Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data collection programs through NCQA. HEDIS is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. HEDIS scores also allow those who are purchasing health insurance to compare the healthcare quality of different health plans. CAHPS® is a nationally recognized survey tool that measures members’ satisfaction with their health plans. To view the most recent HEDIS and CAHPS® scores for Health Alliance, go to HealthAlliance.org/Why.
Health and Wellness
To help you achieve and maintain your best possible health, Health Alliance offers disease management programs for members with asthma, diabetes and high blood pressure. For more information or to enroll, call 1-800-851-3379, extension 8112, and select option 2. Managing a major health condition is never easy. You have full access to our case management programs and will not go through your health journey alone. Our highly skilled nurse case managers personally help members improve their health and reduce their medical cost spend by coordinating quality and cost effective health services. For more information or to enroll, members or their caregivers may call 1-800-851-3379, extension 8112 and select option 1. Other great resources are available to you on our Health and Wellness page: • Quit For Life® smoking cessation program • More information about Rally, our health management tool that helps motivate you with online missions, support and rewards • Immunization Program for adults and children • Our blog, which features articles on health, wellness and insurance subjects • More information about our case and disease management programs • Exclusive discounts at various gyms, health clubs and weight loss centers • Nutrition information and recommended preventive services To learn more, visit HealthAlliance.org/Health-and-Wellness.
Pharmacy Benefits and Management Procedures
The Health Alliance Drug Formulary lists the preferred and most frequently used brand-name drugs. It also contains information on other pharmacy management procedures and processes, such as generic substitution, step therapy, preauthorization, managed dose limits and other limits or quotas. To view the Drug Formulary online, log in at YourHealthAlliance.org. Go to the Plan & Benefits tab, and choose the Your Drug Benefits button under the “Prescription Drugs Benefits” section. You may request a paper copy of the Drug Formulary or any other pharmacy materials on the website by calling the Health Alliance Pharmacy Department at 1-800-851-3379, option 4. Physicians may request a Medical Exception for a medication on behalf of a member or request more information by calling the Health Alliance Pharmacy Department at 1-800-851-3379, option 4. Specific information required from the provider is detailed in our online Drug Formulary. The Medical Exception decision may be appealed by contacting Health Alliance Pharmacy at 1-800-851-3379, option 4.
Vaccine Options
You can get a vaccine at any in-network pharmacy that carries the vaccine you need. The pharmacy could require a prescription for certain patients and for some vaccines. Call your pharmacy to ask if you need a prescription and to check that the pharmacy has the vaccine you need. To find in-network pharmacies, call Customer Service at the number on the back of your ID card or go to the Rxtra section on HealthAlliance.org/Pharmacy. If you get a vaccine in a doctor’s office instead of the pharmacy, you might have an office visit copay.
Members Have the Right to an External Review
Appeals are divided into two categories: administrative decisions and denials of coverage based on medical necessity. If coverage for a procedure or health service has been appealed and continues to be denied based on medical necessity, you have the right to an independent third-party review. An independent (or external) review is a review of the Health Alliance decision conducted by an organization that specializes in dispute resolution. The external reviewer has no direct financial interest in connection with the case, and the member will not be charged for external review. In most cases, an external review can be conducted; however, all lines of appeal must have first been exhausted. For more information about this option, please read your policy or call the Member Relations Department at 1-800-500-3373.
Health Alliance Ensures Reasonable Access to Services
Health Alliance is committed to providing members with efficient, cost-effective and quality healthcare coverage. Health Alliance employees never encourage decisions that result in underutilization of care. We do not give financial inducements or set quotas for issuing denials of coverage or care; nor do we keep statistics identifying individual providers and their denial rates. Coverage decisions made by our medical directors, nurse
coordinators, pharmacy coordinators and pharmacists are based only on appropriateness of care and service and the existence of coverage. There are no incentives, financial or otherwise, to encourage barriers to care and services.
Switching from Pediatric to Adult Care
If you’re ready to switch from pediatric (child) to adult health care or have a child who is ready, there are lots of options. Pediatricians typically see children from birth to age 18, but you can stay with your pediatrician if the relationship works. You can choose a primary care physician (PCP) who works in family practice, general practice or internal medicine. To change your PCP or get a list of in-network doctors, call Customer Service at 1-800-851-3379 or log in at YourHealthAlliance.org.
A Choice for Women
Females enrolled in a managed care plan can select a Woman’s Principal Health Care Provider (WPHCP) in addition to a primary physician. WPHCPs are licensed to practice medicine in all its branches and specialize in obstetrics, gynecology or family practice. You may visit a WPHCP without a referral from your primary physician. For more information on selecting a WPHCP, call our Customer Service Department at 1-800-851-3379.
Breast Reconstruction Surgery Is Covered
If you’ve had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomyrelated benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under your plan. Therefore, plan deductibles, copays and coinsurance may apply. If you would like more information on WHCRA benefits, see your plan materials or contact Customer Service.
We Respect Your Privacy
Protecting the privacy of your medical information is a responsibility we take very seriously. Health Alliance follows the Health Insurance Portability and Accountability Act (HIPAA) and other applicable state and federal regulations to ensure that your information is kept confidential. This means we will only use and disclose your information in ways that are permitted by law. If you would like a complete copy of our website Privacy Policy or our Notice of Privacy Practices, please contact the Customer Service Department. This information is also available on any of our websites at the bottom of the page.
DISCRIMINATION IS AGAINST THE LAW Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance:
Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages
If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medical Plans, Customer Service, 301 S. Vine Street, Urbana, IL 61801, telephone: 1-800-851-3379, TTY: 711, fax: 217-365-7494, CustomerService@healthalliance.org. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Customer Service is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-851-3379 (TTY: 711). 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫1-800-851-3379（TTY: 711）。 UWAGA: Jeśli mówić Polskie, usługi pomocy języka, bezpłatnie, są dostępne dla Ciebie. Zadzwoń 1-800-851-3379 (TTY: 711). Chú ý: Nếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. Gọi 1-800-851-3379 (TTY: 711). 주의 : 당신이한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. 1-800-851-3379 전화 (TTY: 711). ВНИМАНИЕ: Если вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. Вызов 1-800-851-3379 (TTY: 711). Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tumawag 1-800-851-3379 (TTY: 711). ستدعاء. تتوفر لك، مجانا، خدمات المساعدة اللغوية، إذا كنت تتحدث اللغة العربية:تنبيه1-800-851-3379 (TTY: 711). Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. Anruf 1-800-851-3379 (TTY: 711). ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. Appelez 1800-851-3379 (TTY: 711). �યા�: તમે વાત તો ગુજરાતી, ભાષા સહાય સેવાઓ, મફત, તમારા માટે ��લ�� છે . કૉલ 1-800-851-3379 (TTY: 711).
注意：あなたは、日本語 、無料で言語支援サービスを、話す場合は、あなたに利用可能です。 1-800-851-3379コール （TTY: 711）。 LET OP: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar zijn. Bel 1-800-8513379 (TTY: 711). УВАГА: Якщо ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні для вас. Виклик 1-800851-3379 (TTY: 711). ATTENZIONE: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. Chiamare 1-800-851-3379 (TTY: 711).
cmp-nondiscnotice15CM-1216
301 S. Vine St. Urbana, IL 61801
Maple Mustard Grilled Chicken
Servings: 4
Ingredients 4 boneless, skinless chicken breast halves Salt and pepper
Preparation 1. Combine maple syrup, mustard and tarragon in a small mixing bowl to make the glaze.
Glaze 1â „2 cup real maple syrup 1 tablespoon Dijon mustard 2 tablespoons fresh tarragon, chopped
2. Sprinkle the chicken with salt and pepper and place on grill over low to medium heat.
Nutrition 244 calories; 2 g fat; 0.5 g saturated fat; 29 g carbohydrate; 28 g protein; 0.3 g fiber; 68 mg cholesterol; 124 mg sodium; 24 g sugar. com-ILFYBFI-0117
3. When you have turned the chicken once, apply the glaze to the chicken with a basting brush. 4. Continue to apply the glaze as needed, making sure both sides of the chicken are fully covered. 5. Cook chicken until done or internal temperature reaches at least 160 degrees. (Recipe from food.com)