BENEFIT
SPRING 2018 | SF
FOR
HEALTHALLIANCE.ORG
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Power Up Your Health Explore our blog to unlock your journey to better health. Go to Blog.HealthAlliance.org for all these features and more.
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B.Look up the phone number of your primary care provider.
Clear Your Path with Our Mobile App Connect to your coverage on the go and find your way through many obstacles with our brand-new Your Health Alliance mobile app. Download the app from the App Store or Google Play to see all it can do for you.
You A.Be
You have a sore throat and don’t know whether to go to the doctor. A.Call the Anytime Nurse Line. B.Ignore home.
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B.Look up your benefits to see how your plan covers lab work.
Make your way through the forest using the mobile app before the germs pile up.
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PHARMACY
You have strep throat and found out it can be treated with an antibiotic. Take as your doctor prescribes and rest easy knowing you're getting the right treatment.
Self-Funded Essentials
Some of this information may not apply to your plan, depending on your plan sponsor’s choices. Read your plan materials to understand your plan’s specific benefits. The summary plan description (SPD) determines all plan benefits, limitations and processes.
Customer Service Is Here to Help
Keep Your Plan Materials Handy
The back of your plan ID card is the first place to look for help with your benefits. Here you’ll find where to call for questions about claims, coverage, appeals, pharmacy issues, preauthorization, utilization management and information about the doctors, clinics and hospitals your plan works with. Your ID card includes the Health Alliance Northwest Customer Service Department number. Representatives will help you with your questions. When necessary, they will direct you to the correct vendor and provider phone numbers to help meet your needs.
Find Answers Online
Call 1-877-750-3515, TTY 711, Monday through Friday, 8 a.m. to 5 p.m. PT.
After normal business hours, leave a message at this number, and your call will be returned the next business day. Please note that all nonurgent review requests received after normal business hours will be recorded as being received the next business day. Please contact the plan administrator named in your summary plan description (SPD) if any of your personal information has changed, including: • Name • Address • Phone number • Number of dependents • Primary care physician, if applicable
To make the most of your benefits, read the latest SPD. If there are amendments, please read those, too, to ensure that you have the most updated information. These materials are a convenient source for quick information about your coverage. If you need additional copies of your plan materials, please contact the plan administrator named in your SPD.
Find convenient answers to your questions online anytime at HealthAlliance.org. It has information about your coverage and Health Alliance Northwest processes, such as: • Health Alliance Northwest’s most recent HEDIS® and CAHPS® scores • Rally®*, a health management tool • Medical and pharmaceutical management policies and procedures, including how Health Alliance Northwest reviews new technology • 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 the service area** • How to get information about in-network physicians and hospitals, including searching for providers**
• Other insurance 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).
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 your deductible and find your copayments or coinsurance • Read the Health Alliance Northwest 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.
HEDIS® and CAHPS® Health Alliance Northwest 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 plan participants’ satisfaction with their health plans. To view the most recent HEDIS and CAHPS® scores for Health Alliance Northwest, go to HealthAlliance.org/Why.
We Speak Your Language
If you are more comfortable speaking a language other than English, try our telephone translation service, Language Line. Health Alliance Northwest provides access to interpreters who speak 200 different languages. Simply call the Customer Service number listed on the back of your ID card and tell them which language you speak.
Health and Wellness To help you achieve and maintain your best possible health, Health Alliance Northwest offers disease management programs for plan participants with asthma, diabetes and high blood pressure. For more information or to enroll, call 1-800-322-7451, extension 8112 and select option 2.
If you need documents translated into a different language, you may request them by calling 1-877-750-3515.
Other great resources are available to you on the Health and Wellness page:
Si usted necesita un interprete para traducir esta información, por favor llamar al teléfono gratis 1-877-750-3515 y pregunte por la “Language Line.” Si usted necesita documentos tradujeron a un idioma diferente, usted puede solicitar que llamando 1-877-750-3515.
Better Service, Better Care
Health Alliance Northwest Quality and Medical Management Departments continually strive to provide programs and tools to help plan participants and providers promote healthy lifestyles. Our goals are to identify the 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 Northwest encourages contracted doctors to consult nationally recognized standards, called clinical guidelines, when providing care to plan participants. 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 Northwest website or contact the Quality Management Department at 1-800-322-7451, extension 8112, option 2, for a copy.
• Quit For Life® smoking cessation program (for participating plans only; check your SPD) • Immunization program for adults and children • More information about Rally, a health management tool that helps motivate you with online missions, support and rewards • More information about disease management program • Nutrition information and recommended preventive services • A blog, which features articles on health, wellness and insurance subjects To learn more, visit HealthAlliance.org/Health-and-Wellness.
Pharmacy Benefits and Management Procedures
Your plan’s drug formulary lists the preferred and most frequently used brand-name drugs. It may also contain information on other pharmacy management procedures and processes, such as generic substitution, step therapy, preauthorization, managed dose limits and other limits or quotas. For information about your prescription drug benefits, including the drug formulary, preauthorization of medications, adverse benefit determinations and appeals, please read your plan materials.
You May 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 or involves rescission (cancellation of your coverage), you may have the right to an independent thirdparty review. An independent (or external) review is a review of the
*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. **Your plan may include providers and services not listed in the Health Alliance Northwest network. Contact Customer Service or check your SPD. ***If you don’t have Internet access, you can request printed copies of the materials on the Health Alliance Northwest website by calling Customer Service.
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 plan participant will not be charged for external review. All lines of appeal must be exhausted before an external review can take place. For more information about this option, please read your SPD or call the Member Relations Department at 1-800-500-3373.
Health Alliance Northwest Ensures Reasonable Access to Services
As your plan partner, Health Alliance Northwest is committed to providing efficient, cost-effective and quality healthcare coverage administration. Health Alliance Northwest 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 Health Alliance Northwest medical directors, nurse coordinators, pharmacy coordinators and pharmacists are based only on appropriateness of care and your plan of benefits. 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 1-877-750-3515 or log in at YourHealthAlliance.org.
A Choice for Women
Most health plans now provide well-woman visits at no extra cost. For more information, contact the Customer Service Department at 1-877-750-3515.
Benefits Are Available For Breast Reconstruction
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 Health Alliance Northwest takes very seriously. Health Alliance Northwest 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 Health Alliance Northwest will only use and disclose your information in ways that are permitted by law. If you would like a complete copy of the Health Alliance Northwest website Privacy Policy or Notice of Privacy Practices, please contact the Customer Service Department. This information is also available on any of the Health Alliance Northwest websites at the bottom of the page. For a copy of your plan’s Notice of Privacy Practices, contact the plan administrator named in your SPD.
DISCRIMINATION IS AGAINST THE LAW Health Alliance Northwest 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 Northwest does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance Northwest: • 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 Northwest 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 Northwest, Member Services, 316 Fifth Street, Wenatchee, WA 98801, telephone: 1-877-750-3350 TTY: 711, fax: 217-337-3425, MemberServices@healthalliance.org. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Member Services 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 1-877-750-3350 (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1-877-750-3350（TTY: 711）。 UWAGA: Jeśli mówić Polskie, usługi pomocy języka, bezpłatnie, są dostępne dla Ciebie. Zadzwoń 1-877-750-3350 (TTY: 711). Chú ý: Nếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. Gọi 1-877-750-3350 (TTY: 711). 주의 : 당신이한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. 1-877-750-3350 전화 (TTY: 711). ВНИМАНИЕ: Если вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. Вызов 1-877-750-3350 (TTY: 711). Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tumawag 1-877-750-3350 (TTY: 711). ﺍﺳﺘﺪﻋﺎء. ﺗﺘﻮﻓﺮ ﻟﻚ، ﻣﺠﺎﻧﺎ، ﺧﺪﻣﺎﺕ ﺍﻟﻤﺴﺎﻋﺪﺓ ﺍﻟﻠﻐﻮﻳﺔ، ﺇﺫﺍ ﻛﻨﺖ ﺗﺘﺤﺪﺙ ﺍﻟﻠﻐﺔ ﺍﻟﻌﺮﺑﻴﺔ:ﺗﻨﺒﻴﻪ1-877-750-3350 (TTY: 711). Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. Anruf 1-877-750-3350 (TTY: 711). ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. Appelez 1-877-750-3350 (TTY: 711). ધ્યા: તમે વયત તો �ુજરયતી, ભયષય સહય્ સેવયઓ, મફત, તમયરય મયટ� ઉપલબ્ છે . કૉલ 1-877-750-3350 (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。 1-877-750-3350コール（TTY: 711）。 LET OP: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar zijn. Bel 1-877-750-3350 (TTY: 711). УВАГА: Якщо ви говорите український, вставки послуги мовної допомоги , безкоштовно, доступні для вас. Виклик 1-877-750-3350 (TTY: 711). ATTENZIONE: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. Chiamare 1-877-750-3350 (TTY: 711). cmp-nondiscnotice15NW-0617
316 Fifth Street Wenatchee, WA 98801
Healthy Apple “Donut” Slices with Coconut Cream Cheese Frosting Ingredients
Preparation
2 apples
1. In a mixing bowl, whisk together the cream cheese, yogurt, vanilla, coconut oil and food coloring (if using) until smooth and creamy, about 1 minute. Refrigerate while preparing apples or until you’re ready to use it.
4 ounces whipped cream cheese 4 ounces honey Greek yogurt (or plain) 1 tablespoon coconut oil (can omit if desired) 1/2 teaspoon vanilla extract
2. Slice apples and remove each core from center using a knife or pastry tip.
2 drops food coloring (optional)
3. Spread frosting on top of each apple slice.
Sprinkles
4. Dust with preferred sprinkles.
Nutrition 154 calories; 9 g fat; 6 g saturated fat; 17 mg cholesterol; 13 g sugar; 113 mg sodium; 18 g carbohydrate; 2.5 g dietary fiber; 3 g protein; 86 mg potassium.
Servings: 4 (Recipe modified from TheQuikChik.com.) com-NWSFFYB-0118