House Calls: Choose Health - Washington Spring 2015

SPRING WA

Health or Wellness or

Choose

Health Call us 8 a.m. to 8 p.m. weekdays • Toll-free 1-877-750-3350 • TTY/TDD 711

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From the Editor:

Let’s Put the Puzzle Together

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hen it comes to staying safe and healthy, there are lots of choices to make—from what kind of health professional to see to whom you can trust with personal information. Any life decision can be puzzling.

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This issue of House Calls covers a few common choices you may face. As you read, you’ll see we want to be more than your Medicare plan. It’s our goal to be your partner in keeping you safe and healthy. If you have any questions, we are happy to help. Call Member Services at 1-877-750-3350, weekdays from 8 a.m. to 8 p.m.

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Health Alliance Medicare wants to help you piece the puzzle together and understand your options.

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Happy with Your Plan?

Tell Us What You Think

We are looking for Health Alliance Medicare members from Sangamon, Peoria, Christian and Macon counties to join our advisory board. We want to hear your ideas, and this is a great way for us to learn what kinds of questions our members have about our plans and staying healthy.

Caregivers are welcome, too.

If you’re happy with your plan and willing to tell others about it, please contact Nicole Mechling at 1-800-851-3379, ext. 8574, or Nicole.Mechling@healthalliance.org.

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To join or learn more, call Jennifer Marquardt at 1-800-851-3379, ext. 8439, weekdays from 8 a.m. to 5 p.m. TTY/TDD users call 711.

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1-800-Where Am I Calling? ▼ ▼

You might wonder why you need to dial a toll-free number to reach us. If you’re talking to someone in Wenatchee, why can’t you call a local number?

We heard your concern and want to share the reason. When you call a local 509 number, that line can only hold a maximum of five callers at once. If the number of callers is above that, you could get a busy signal.

To make sure you can get through, call 1-877-750-3350.

Our local staff is happy to help.

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HealthAllianceMedicare.org

You Have Options for Your Health Care

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hen you’re feeling sick, or you’re ready for your next checkup, you call your main doctor or PCP (primary care physician or provider) to set up an appointment.

Sometimes, he or she can’t see you as quickly as you need, so you might see a physician assistant (PA) or nurse practitioner (NP) instead. And some people even have a PA or NP as their PCP. Both PAs and NPs go through medical training and education. They must be certified by the state they are working in, and they usually have master’s degrees.

With PAs and NPs, you’re getting great care from trained healthcare professionals who know all about ways to keep you healthy.

They do many of the same things doctors do, like examine and diagnose patients. If their state laws don’t allow them to prescribe meds, they work with doctors who can.

Often, PAs and NPs have more flexible schedules than doctors. This might give you a chance to get an appointment on shorter notice. PAs and NPs often have more one-on-one time for you, too, so they can get a full picture of your health.

Both PAs and NPs have the knowledge and ability to help you understand what’s going on with your health, so you pay the same copay as you would a doctor.

They are providers you can trust.

If you prefer to see a medical doctor, you can, but you might wait longer and get less oneon-one time with him or her.

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Take a Minute to Care about Caregivers

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ary Ulrich, a second-year Health Alliance Medicare member, likes a challenge. The one-time drafter and surveyor at an engineering firm went from designing layouts for Wenatchee Valley’s buildings and subdivisions to taking photos on the frontlines of wildfires.

The toughest challenge he faced wasn’t learning the art of drafting by hand before the drafting world went digital, and it wasn’t going out on his first fire call to take pictures of people putting their lives on the line to save others. It wasn’t even a challenge he enjoyed, but it was his most important—being a caregiver for one of the people he loves most, his wife.

Sharon Ulrich was diagnosed with Alzheimer’s (a type of dementia) after showing some confusing symptoms, like having visions of everything from Old English-style visitors to spies and people trying to break into her home.

At first, doctors couldn’t figure out what was wrong.

Was it depression? Dementia? And if she had dementia, what kind was it? At 63 years old, she seemed too young for that.

While doctors looked for answers, Cary stayed by his wife’s side. From her earliest symptoms and first diagnosis in March 2010 to moving her to an adult home in February 2013, Cary was a caregiver. And he quickly learned that being a caregiver can take its own toll.

“I was on the outside going through everything,” he says. “I was very frustrated and angry at the situation, not at her. I had all those feelings, and no one seemed to care about me.”

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He watched his wife’s health get worse while knowing he couldn’t help her get better. The woman who’d walked past his back-row church pew almost two decades ago, the one he thought was way too classy to ever even talk to him, now needed him to be her caregiver.

“It’s a hard process,” he says. “I don’t exactly know how I did it, but I’ve gotten to the point where I’ve had to let go of what was and just totally accept her for the person she is now.”

Cary never backed down. Instead, he used his experience of caring for a loved one with dementia to help others do the same, turning his negative situation into something positive.

Today, Cary helps run two caregiver support groups— one specific to dementia at the Grief Place of North Central Washington and a more general one at Aging and Adult Care of Central Washington in East Wenatchee. In both groups, Cary gives support and tips to other caregivers because he believes it will help them feel better and make smarter choices about their own loved ones.

“The more you know when these things happen, the more you can kind of accept them,” he says.

“You know you’re going to have to change because your loved one has changed and can’t go back the other way.”

He also talks to nursing classes at Wenatchee Valley College and to first responders in different fire districts to help them know how to work with people with dementia and the family and friends who care for them.

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Cary takes on other challenges, too, like helping put on the annual Walk to End Alzheimer’s in Wenatchee. Last year, he lined up sponsors, set up and took photos for the 2-mile event that raised money and awareness.

Cary’s selflessness shines through in everything he does, and the man who likes to take on challenges and still goes out on fire calls hopes to make caregivers’ lives less challenging in the future.

“As a caregiver, you have the memories of what was, but all you have is what is. It’s a very difficult place to be. I know what these caregivers are going through, though.

And I want them to know they are valued and can still enjoy life.”

Take Care of Yourself, Too We know being a caregiver is hard work and can take up a lot of your time, but remember to take care of yourself, too. Talk to your friends and family about how you feel. Take time to do something you enjoy, and don’t be afraid to ask for help. You deserve it.

To learn more about Cary’s support groups and all the great services these organizations offer, check out aaccw.org and griefplace.org. Cary’s group at Aging and Adult care meets the second and fourth Wednesdays of the month from 3:30 to 5 p.m., and his group at Grief Place meets the first and third Wednesdays from 6:30 to 8 p.m.

The 2015 Walk to End Alzheimer’s is set for September 12. For more information, go to alz.org/alzwa and choose “Walk to End Alzheimer’s” on the left.

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Diabetes—Getting Tested and Next Steps

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ore than 29 million Americans have diabetes, and about 25 percent are adults 65 and older, according to the Centers for Disease Control and Prevention.

Diabetes is a problem with your body that makes your blood glucose (sugar) levels higher than normal. There are two kinds of diabetes—type 1 and type 2. About 90–95 percent of Americans with diabetes have type 2.

One in four people with diabetes don’t even know they have it. Finding out if you have diabetes is important. It could even save your life.

Your doctor can test you for diabetes with the fasting plasma glucose test or A1C test. Everyone 45 or older should get tested. If you haven’t been tested lately, ask your doctor if you need to be.

You can cut your risk for type 2 diabetes in half by: If you find out you have type 2 diabetes or prediabetes—blood glucose levels that are higher than normal but not yet high enough to be diabetes—you can make healthy changes.

• Losing 7 percent of your body weight (for example, 14 pounds if you weigh 200 pounds) • Exercising moderately for 30 minutes a day, five days a week

Your doctor might prescribe a pill or insulin to help you meet your blood glucose goals, but you can also help control your levels by eating healthy and being active. If you have prediabetes, making these lifestyle changes can even help you prevent diabetes.

If you have been diagnosed with diabetes or prediabetes, talk to your doctor about a treatment plan that’s right for you. Health Alliance Medicare also has on-staff health coaches who can support and guide you as you make healthy lifestyle changes. To learn more or to talk with a health coach, call 1-800-851-3379, extension 8112.

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Protecting Your Medical Records and Personal Info

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ecently, one of the nation’s largest health insurance companies, Anthem, had a massive data breach after it was the target of a cyberattack. As many as 80 million people’s records, including Social Security numbers, addresses and income data, were leaked.

After this breach, we want to reassure you that we take protecting our members’ personal information very seriously. We have an extensive information security program that follows all regulatory security requirements to protect your privacy. We have an in-house Special Investigations Unit that looks into any reported medical identity theft from our members.

What You Can Do Help protect your personal information by taking these steps.

Don’t share personal, medical or insurance information by phone or email unless you know who you’re dealing with. Medicare and Health Alliance Medicare will never ask you out-of-theblue for personal info. Other places, like a doctor’s office, should not ask for your personal info unless they can prove who they are—and you have the right to ask for proof.

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Never share your Health Alliance Medicare ID card with anyone, and keep it in a safe place.

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We encrypt any sensitive data we send electronically. All employees go through annual training and testing to make sure they understand which information must be protected and the importance of maintaining that protection.

Keep paper and electronic copies of your medical and health insurance records in a safe place. Shred outdated paper copies.

No health plan, including us, can guarantee it will never be the victim of a cyberattack.

But we can assure you that we’re doing all we can to protect your information every day.

Report anything you think might be fraud by calling 1-877-7SAFERX (1-877-772-3379) or the Health Alliance Compliance Line at 1-855-371-4640. Speaking up could protect you or someone else.

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HealthAllianceMedicare.org

Health Coaches Help You Make Healthy Changes

“It’s a really rewarding experience to see members prepare for and accomplish their goals.”

Alayna Hirsch Certified Health Coach

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ometimes choosing to make a healthy lifestyle change can be half the battle.

And once that’s done, it can be hard to know where to start. (It seems much easier to squeeze in a few more pages of your favorite magazine, right?) Once you finally get going, you might need help to stay on track. (We know how tempting that last piece of cake and a comfy couch can be.) Well, Health Alliance Medicare has a team of three health coaches to help you put down the cake and start moving.

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Meet one of our health coaches to find out what the team does and how it can help.

Alayna Hirsch has been a Certified Health Coach for two years and has been supporting Health Alliance members for the past year. Here’s what she had to say about the program.

How does it work?

AH: Coaches partner with Health Alliance members to provide information and support on topics, such as nutrition, weight management, physical activity, diabetes and heart health. The coach and member talk on the phone once a week to once a month based on each member’s needs.

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What do you spend most of your time doing as a health coach?

AH: Our time is spent on the telephone with members offering support and partnering with them to meet their health goals. We help them navigate the change process.

What is your favorite part of the job?

AH: My favorite part is building relationships with members and supporting them as they manage their health. It’s a very rewarding experience, especially when members overcome barriers to achieve success.

What made you choose this career?

AH: I chose this career because I really enjoy helping people navigate the process toward a healthier self. As a health coach, I have an opportunity to empower people to focus on themselves, so they can make positive lifestyle changes that can lead to better long-term health.

What has been a rewarding experience for you as a health coach?

AH: It’s a really rewarding experience to see members prepare for and accomplish their goals.

What do you want members to know about what you do?

AH: Plenty of people want to tell you what to do, but that’s not our job. We don’t judge. We give support and help our members find their motivation to make small changes that lead to lasting results.

If you or someone you know is going through major health changes, give our health coaches a call to see if they can help. The program is free and flexible. To learn more about this program or to talk with a health coach, call 1-800-851-3379, extension 8112.

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Essentials Health Alliance Medicare Services is Here to Help 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 we will return your call 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 us if any of your personal information has changed, including: • Name • Other insurance • Address • Primary care physician (PCP) • Phone number You can call Health Alliance Medicare Services at 1-877-750-3350, Monday–Friday, 8 a.m. to 8 p.m. PT. TTY/TDD users call 711.

Keep Your Member Materials Handy To make the most of your benefits, read your member materials, including your annual Evidence of Coverage book and any materials you received when you became a member. These materials are a convenient source for quick information about your coverage.

If you need additional copies of your member materials, please contact Health Alliance Medicare Services at 1-877-750-3350, Monday–Friday, 8 a.m. to 8 p.m. TTY/TDD users call 711.

Take Charge Online You can often find convenient information and tools online at YourHealthAlliance.org. Simply log in* with your username and password to:

• How to obtain emergency care, primary care, specialty care and behavioral health services during and after normal business hours in and out of the service area

• View eligibility

• How to obtain information about in-network physicians and hospitals, including searching for providers

• Find copayments or coinsurance • Check the status of a claim • View member rights • Look for a participating and responsibilities provider • Order a new ID card

• How to file a complaint or appeal, including your right to involve an external review organization

• Read the Notice of Privacy Practices

• View the Health Alliance ® ® Medicare Part D Formulary • Review HEDIS /CAHPS results and other quality • Evaluate drug interactions, initiatives view drug claims history • Pay your monthly premium and see how much you’ll pay for prescriptions • Access our online health management platform

*To sign up for a username and password, follow these steps: 1. Go to YourHealthAlliance.org.

2. Click “Register.”

3. Enter the requested information and click “Send Confirmation Email.”

4. Log in to your email account to verify your email address by following the link provided in the confirmation email.

You’ll also find information about: • Medical and pharmaceutical management policies and procedures, including how we review new technology

*If you don’t have Internet access, you can request printed copies of the materials on our website by calling Health Alliance Medicare Services.

• Claims submission • Which benefits and services are included and excluded from your coverage in and out of the service area

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®).

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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 Health Alliance Medicare Services and state which language you speak.

Si usted necesita un interprete para traducir esta información, por favor llamar al teléfono gratis 1-877-750-3350 y pregunte por la “Language Line.”

Documents may be available in alternate formats or languages. Please call 1-877-750-3350, Monday–Friday, 8 a.m. to 8 p.m. TTY/TDD users call 711.

Better Service, Better Care Health Alliance Quality and Medical Management continually strives 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 HealthAllianceMedicare.org and choose “Why Us?” Then click the link under “Quality in Numbers” to view HEDIS® scores and learn about the Quality Improvement program.

Clinical Guidelines Health Alliance encourages our doctors to consult nationally recognized standards, called clinical guidelines, when providing care to our 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 call 1-800-851-3379, ext. 8112 (Monday– Friday, 8 a.m. to 5 p.m CT) for a hard copy. TTY/TDD users call 711.

NCQA® Accreditation We participate in a health plan accreditation program with the National Committee for Quality Assurance (NCQA®).

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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 Data and 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 performance in terms of clinical quality and customer service. CAHPS® is a nationally recognized survey tool that measures members’ satisfaction with their health plan. To view the most recent HEDIS and CAHPS® scores for Health Alliance, visit HealthAllianceMedicare.org. Choose “Why Us?” at the top. Scroll down and click the link under “Quality in Numbers.” Then scroll down to “Our HEDIS® Score.”

Safety Health Alliance is committed to improving healthcare safety so our members with medical problems do not feel worse because of an error during treatment. Our Adverse Events Committee oversees patient safety initiatives. Patient safety suggestions and articles are also available on HealthAllianceMedicare.org.

Choose “Why Us?” at the top. Scroll down and click the link under “Quality in Numbers.” Then scroll to the bottom and select “See the detailed structure of our Quality and Medical Management program.”

Health & 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.

The case management program serves members who need help managing a chronic or complicated health condition or navigating the healthcare system. For more information or to enroll in any of these programs, members or their caregivers may call 1-800-851-3379, extension 8112, Monday–Friday, 8 a.m. to 8 p.m. CT. TTY/TDD users call 711.

Other great resources are available to you on our Health and Wellness page:

• 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 • Members also have access to Healthway’s SilverSneakers® fitness program. (For more information, call 1-877-750-3350, Monday–Friday, 8 a.m. to 8 p.m.

TTY/TDD users call 711.)

To learn more, visit HealthAllianceMedicare.org and click the Health & Wellness link at the bottom of the page.

• Quit For Life® smoking cessation program • Immunization Program for adults and children

Pharmacy (Part D) Benefits and Management Procedures Formulary The Health Alliance Medicare Part D formularies were created to assist in the management of ever-increasing costs of prescription medications.

Formularies have successfully helped health insurance organizations throughout the country provide members and physicians with a reference for cost-effective medical treatment.

Our formularies also contain information on other pharmacy management procedures and processes, like step therapy, generic substitution, preauthorization, therapeutic interchange, quantity limits and other limits or quotas.

To view our formulary online, visit HealthAllianceMedicare.org and choose the Pharmacy tab at the top. Then click the link under “Formulary” on the next page. To search within the document, choose the search function (the picture of binoculars or Ctrl + F), enter a drug name and click “Search.”

For more information on your pharmacy benefits and our management procedures and processes, visit HealthAllianceMedicare.org and choose the Pharmacy tab at the top. Then click the links under “Pharmacy Choice.”

Call us 8 a.m. to 8 p.m. weekdays. Toll-free 1-877-750-3350, TTY/TDD 711.

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

Medicare Services at the number on the back of your ID card or log in at YourHealthAlliance.org and choose “My Drug Benefit” on your Member Dashboard. If you get a vaccine in a doctor’s office instead of the pharmacy, you might have an office visit copay.

We Partner with Physicians We regularly seek input from all doctors in our network regarding policies under development or review.

Through regular (every other month) e-newsletters,

we communicate with our physician network. Practicing physicians are also involved on several of our committees to foster idea-sharing and improve the quality of our programs.

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You Have the Right to an Independent Review For members with Medicare Part C medical benefits, if we deny any part of your first appeal, the entire case, including your appeal letter, will automatically be forwarded for another review with a governmentcontracted independent review entity (IRE).

by a government-contracted independent review entity (IRE).

You must file a written appeal request within 60 calendar days after the date you were notified of the decision on your first appeal to the address included in the redetermination notice you receive from us. For more information, please read your Evidence of Coverage or call 1-800-500-3373, Monday–Friday, 8 a.m. to 5 p.m. CT. TTY/TDD users call 711.

For members with Medicare Part D prescription drug benefits, if we deny any part of your first appeal, you or your appointed representative may ask for a review

Health Alliance Ensures Reasonable Access to Services Health Alliance is committed to providing you with efficient, cost-effective, quality healthcare coverage.

Health Alliance never encourages underutilization of care. We do not give financial inducements or set quotas for denying care or coverage, nor do we keep statistics identifying individual providers and

their denial rates. The utilization decisions our medical directors, nurse coordinators, pharmacy coordinators and pharmacists make are based only on appropriateness of care and service and the existence of coverage. There are no incentives, financial or otherwise, to deny access to services.

We Respect Your Privacy Protecting your medical information is a responsibility we take very seriously. Health Alliance follows Health Insurance Portability and Accountability Act (HIPAA) and other 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. For a complete copy of our website Privacy Policy or our Notice of Privacy Practices, please contact Health Alliance Medicare Services.

This information is also available on our website at HealthAllianceMedicare.org.

Planning Ahead You have a right to accept or refuse treatment and to complete an advance directive. If you’re not satisfied with how we’ve handled an advance directive, you have the right to file a complaint with the state survey and certification agency. Information on

advance directives and how to file a complaint if your instructions are not followed are addressed in your Evidence of Coverage.

For more information, contact Health Alliance Medicare Services to request a copy of the brochure “Planning Ahead.”

Call us 8 a.m. to 8 p.m. weekdays Toll-free 1-877-750-3350 TTY/TDD 711 HealthAllianceMedicare.org

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Health Alliance Medicare is an HMO plan with a Medicare contract. Enrollment in Health Alliance Medicare depends on contract renewal.

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HEALTH ALLIANCE 316 FIFTH STREET WENATCHEE, WA 98801

PRSRT STD U.S. POSTAGE PAID CHAMPAIGN,IL PERMIT NO. 488

Calendar of Events:

• Walk to End Alzheimer’s, Pybus Public Market, Wenatchee, WA, September 12, 9:30 a.m.

• Walk to End Alzheimer’s, Yonezawa Park, Moses Lake, WA, September 19, 10 a.m.

• Central Washington Health and Wellness Expo, Big Bend Community College, Moses Lake, WA, September 26, 9 a.m.–3 p.m.

Health Alliance Medicare is an HMO plan with a Medicare contract. Enrollment in Health Alliance Medicare 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, formulary, pharmacy network, provider network, premium and/or co-payments/ co-insurance may change on January 1 of each 16 year.