Teachers Health Trust Health Traxx: Volume 15 | Issue 2 | Summer 2016

Health

A Publication for Teachers Health Trust Participants

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Summer 2016 │Volume 15, Issue 2 For Teachers by Teachers

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TRAVEL SAFE. VOLUME 15, ISSUE 2

REFERRALS

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contents SUMMER 2016

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Travel Safe.

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IN THIS ISSUE LETTERS 4 BOARD OF TRUSTEES What do you think being healthy means?

5 FROM THE CEO

FEATURES 7 PERFORMANCE PLUS PLAN How to obtain a referral for a specialist visit.

8 WHO DO I CONTACT? When to call your Healthcare Advocate or Member Services.

9 REFERRALS 101 Step-by-step instructions on how to see a specialist.

10 TRAVEL SAFE Travel with healthcare in your hands.

12 REFERRALS & PRIOR AUTHORIZATIONS A review of differences and importance.

13 HERE’S TO HEALTH An overview of the different health programs available to you.

15 SERVICES REQUIRING PRIOR AUTHORIZATION Learn more about which procedures require prior SUMMER 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG

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Health Traxx is published quarterly by the Teachers Health Trust to help participants make life-saving decisions about health care. Although editorial content is based on sound medical information, we ask that you consult a health care professional regarding all medical concerns. We encourage you to keep copies of this news publication for the purpose of building a handy home medical reference guide or to recycle issues to friends and family. Any opinions expressed by an author/source whose article appears in this publication are solely the opinions of the author/source and do not necessarily reflect the views of the Trust. If you have questions or comments regarding this issue, e-mail the Trust at wellness@ teachershealthtrust.org, or write to Teachers Health Trust c/o Meghan Bailey, P.O. Box 96238, Las Vegas, NV 89193-6238.

CHAIRPERSON Michael Steinbrink VICE CHAIRPERSON Isela Stellato BOARD OF TRUSTEES David Tatlock Jodi Brant Cindy Johnson Molly Lehman Kerri Martinez Najera Cynthia Rapazzini Vikki Courtney, CCEA President MARKETING & MEDIA Meghan Bailey, Director ART & DESIGN Sarah Harper COPY EDITING Nick Dawson ADVERTISEMENTS This publication is made in part by the generous donations of network providers and non-profit community organizations. Individuals or companies interested in advertising opportunities in Health Traxx should contact Meghan Bailey, Director of Marketing & Media, at wellness@teachershealthtrust.org or contact the Teachers Health Trust Wellness Division at (702) 866-6192. An advertisement in the Health Traxx publication does not mean the Trust endorses the provider or service. Ad purchase space is based on a first-come, first-served basis, and advertisers are preferred to be a part of the Teachers Health Trust Provider Network. Other organizations, such as non-profit local or national health agencies or forprofit companies with a valid business license, may advertise once approved by the Teachers Health Trust Special Events Committee.

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SUMMER 2016 | VOLUME 15, ISSUE 2 HEALTH TRAXX MAGAZINE

LETTERS

FROM THE BOARD

What do you think being healthy means?

As a board, we are always looking for new ways to help our fellow teachers stay healthy.

Teachers know, of course, what is healthy and what is not. I remember sitting through several classes with my students hearing the presentation of how to be healthy, but when it comes to teachers, it’s really all about time. How do you eat healthy when you have papers to review, IEPs to attend, lesson plans to write, tests to grade, especially this time of year with grades and finals? It’s tough to stay healthy in today’s fast food, junk food, processed food world.

As we work on teaming up with WellHealth and our hospitals and doctors, our goal is to educate the educator on being healthy. We’re using innovative ways to make the transition to healthier living easier. Bringing aboard WellHealth and our new CEO has been one approach to bring about better health and healthcare for teachers and their families. As healthcare costs continue to rise, we have to adapt to make sure those costs have a minimal effect on our wallets. Living healthier is one way we can all save money.

As we move forward, we ask that you be patient as we transition to a better healthcare delivery system -- a system that will support healthier lifestyle training for all of us. Though the transition has been hard for some, we are striving with our partners to ease the hassle and confusion as we move forward with our new plan.

Please remember, everyone on the Teachers Health Trust Board of Trustees is also a teacher with the same issues and concerns you have. We are all affected by these changes, but we are constantly working to make sure problems are being addressed as quickly as possible.

If you have thoughts, ideas, suggestions or comments relating to the important benefits being offered, please feel free to reach out to your board via the Trust Service team. Remember also to go to teachershealthtrust.org for continual updates and important notices throughout the summer season and beyond.

The Teachers Health Trust Board of Trustees appreciates your continued support as we work to make our insurance and our profession the healthiest and the best it can be.

Board of Trustees Teachers Health Trust

LETTERS

FROM THE CEO

Letter from our CEO Gary Earl I would like to take the opportunity to thank each of you for your kind and warm reception as I acclimate to the role of CEO of your Teachers Health Trust. I also want to express my gratitude for your patience as we work to solve the noticeable challenges we face.

Currently, the Trust has evolved from simply handling operations and management to overseeing health and economic improvements, design, and building upon its rich legacy of programs and services.

It is important to appreciate that health and healthcare innovation creates challenges.

Transformation surges against traditional models; however, without change in the structure of our Trust, the programs and policies that were built by teachers for teachers would simply not be sustainable. The renovations that were necessary, as well as modernizations that are presently occurring, are framed upon a foundation of improvement. The re-engineering is tracking a well architected strategy and design that exceeds today’s classic approach to health and well-being. Together, with our valued provider-partners, our collective mission, focus and commitment is to fully implement and deliver to you and your family a robust, relative and valuable health and well-being platform from which both health conditions and economics can be improved upon. The framework for this novel approach contains pioneering programs, process and policies built upon crucial elements of success including emerging education and engagement technologies, value-based physicians, quality and access outcomes, and advanced health and well-being initiatives that go beyond an individual’s personal health dimension, but also into our social dimensions of health. It is critical that we work effectively and efficiently to deliver to you and your family a healthcare system that provides high-quality care that addresses the immediate medical needs of the individual. At the same time, we must maintain a secondary focus on the broader social and environmental determinants of health, which represents a proactive shift toward a more comprehensive approach that accounts for expansive, interconnected, interdependent and deeply personal expressions of health. In order to achieve both success and significance, together, we are rethinking health.

In the spirit of full transparency, I personally and professionally acknowledge that we are not at a time or place where we can yet celebrate success. Our service standards, including telephone hold and electronic response rates, are subpar. There remains confusion on how to effectively navigate the new system of care. There are policy complications that need to be eliminated by revisiting, modifying and rebuilding. We at the Trust live the challenge each and every day, as do you. We are aware of as well as sensitive and committed to improvement; in fact, it is our singular focus.

In order to, ultimately, achieve our shared goals, we need your participation. We need to hear and learn from you of the many challenges you face. We also need to understand what YOU, as the consumer, see as the unique challenges you face when it comes to health and well-being. This is far more than an employee medical benefit program. Rather, your Trust is evolving to become an important source for improving your overall quality of life. To accomplish this lofty ambition, we need not only your voice, but also your continued patience. My personal hope and request is that you will allow us this privilege as we continue to work diligently on your behalf to create a Trust that you can truly trust.

On behalf of our family at the Trust and our most valued partners, we wish you, collectively, a most peaceful and healthy summer season.

Gary Earl, CEO GEarl@teachershealthtrust.org SUMMER 2016 | VOLUME 15, ISSUE 2 HEALTH TRAXX MAGAZINE

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FEATURES New or Pre-existing Relationships with Specialists Referrals to specialists from a Patient-Centered Medical Home (PCMH) provider allows for better coordination of care, especially for patients dealing with multiple medical conditions. For your convenience, referrals may be obtained in a number of ways.

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Visit or call your PCMH provider and discuss with them about your needs for new or ongoing referrals. Some providers may allow this to be done over the phone.

Others may want to see you in their office.

Call or email your Healthcare Advocate to generate the referral if you have a pre-existenting relationship with a specialist. A pre-existent relationship is defined as an office visit or service provided by the specialist between January 1, 2015 and March 31, 2016.

A referral request form will be required, which is available on the Teachers Health Trust website.

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Your Healthcare Advocates can be reached at (855) 4049355 or by e-mail at advocates@wellhealthqc.com. If you have any questions, you can always simply call the Teachers Health Trust Members Services line at (702) 794-0272 and a representative will be happy to help you through this process.

PLEASE NOTE

Occasionally, when a provider refers you to a specialist, it may take some time to get a reply. If you experience a delay in receiving information back on your referral, this is usually the reason. Sometimes, this delay is mistakenly assumed to be the result of an approval/denial process.

This is not the case. The referral process is not a matter of approval or denial. It is not Teachers Health Trust’s or WellHealth’s role to determine if you need to see a specialist. That is the role of your PCMH provider.

The goal of obtaining a referral to a specialist is not to slow down your care or cause you ANY restrictions, but rather allows us to measure the quality and effectiveness of your experience.

OB/GYN AND PEDIATRIC REFERRALS

If you have a secondary PCMH with an OB/GYN or your dependents are seeing a pediatrician, these providers may generate referrals using their same internal process as before. The participant will not be penalized financially; co-payments and co-insurance will remain as if the referral was generated electronically. These providers will be transitioned to the electronic system in the fourth quarter of 2016. Please note that specialists (other than the above) cannot refer a participant to another specialist.

SUMMER 2016 | VOLUME 15, ISSUE 2 HEALTH TRAXX MAGAZINE

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who do i contact? contact a

HEALTHCARE ADVOCATE if you need to Find an in-network provider or confirm a Patient-Centered Medical Home provider Schedule appointments for complex care medical conditions Send new, pre-existing, or retro-active referrals Find or file a Provider Change Request form Request, obtain, or send medical records Discuss or enroll in Here’s to Health programs (Diabetes, Heart Health, High-Risk Pregnancy, and Asthma/COPD) Get answers to questions regarding the WellHealth app or website Ask questions regarding Telemedicine and Teletherapy Contact Healthcare Advocates by e-mail at advocates@wellhealthqc.com or by phone at (855) 404-9355.

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MEMBER SERVICES if you need to Ask in-depth benefits questions Get answers about eligibility questions Get information about prescription refills Receive information regarding prescription costs or co-pays Add or remove dependents from a policy Get policy payments or reimbursement information Ask about claims or an explanation of benefit details Ask billing questions Contact Member Services by e-mail at serviceteam@teachershealthtrust.org or by phone at (702) 794-0272.

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SUMMER 2016 | VOLUME 15, ISSUE 2 HEALTH TRAXX MAGAZINE

Referrals 101 I have not seen a specialist before.

OPTION ONE

If you have never seen a specialist, you will need to visit your Patient-Centered Medical Home (PCMH) provider. During your appointment, you can discuss your needs and concerns. If your PCMH doctor agrees that you need to see a specialist, they will issue you an electronic referral via par8o. A copy of the referral should be given to you and you may receive a text reminder of the appointment.

OPTION TWO

If you have an established relationship with your PCMH, you may call and request a referral.*

I have an existing relationship with a specialist.

If you have seen a specialist or had a service performed between January 1, 2015 and now, a Healthcare Advocate may be able to issue a referral for you. Fill out the Referral Request form found on the Teachers Health Trust website in its entirety. Attach necessary documentation and email it to advocates@wellhealthqc.com or fax it to (702) 357-3447.

I need a referral from an OB/GYN or pediatric provider.

Your OB/GYN or pediatrician can continue to issue non-electronic referrals as before. These offices will have the electronic par8o system sometime in the third quarter of 2016. A provider visit may be necessary to generate a referral. If you have an established relationship with your provider, they may be able to issue a referral for you.*

I cannot go through the regular referral process.

If you find yourself in this situation, do not wait. Go see your specialist and know that after your visit, yourself or your provider can contact the Healthcare Advocates for a Retroactive Referral. If it’s a true emergency, go to the emergency room. If your provider office is not currently in par8o, they can still send a referral on your behalf via fax, paper, or a phone call.

*Please note: Participants who have an established relationship with their PCMH Provider may only need to call to start the referral process.

If you have additional questions, please call your Healthcare Advocate at (855) 404-9355.

SUMMER 2016 | VOLUME 15, ISSUE 2 HEALTH TRAXX MAGAZINE

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FEATURES

Travel Safe.

Travel with Healthcare in Your Hands

Teachers Health Trust Performance Plus Health Plan participants now have the ability to access medical and behavioral health providers 24 hours a day, 7 days a week through our virtual care program powered by MDLive.

Providers can diagnose and treat conditions, such as the cold and flu, fever, strep throat, conjunctivitis (pink-eye), sinus infections, rashes and more. Also, teachers will have access to counselors and therapists to talk through everyday stressors, when the need arises.

If you have not yet done so, log onto WellHealthOnline.com, and create your health profile to access a telemedicine or teletherapy provider when you need to see one as you travel this summer.

You can access your virtual care benefits anywhere within the U.S. (except Arkansas), including three U.S. territories: Guam, Virgin Islands, and Puerto Rico.

If you have any questions on how to register or when to use virtual care, you can call (866) 327-4873.

Visit WellHealthOnline.com to register! Don’t forget to put ‘00’ at the end of your Trust ID number to register.

HOW TO ACTIVATE

YOUR ACCOUNT 1

Open your web browser (Safari is NOT compatible with any telemedicine platform. We recommend Chrome, Firefox, or Internet Explorer.)

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Click on the red ‘ActivateNow’ button.

Enter the URL WellHealthOnline.com

Enter your Trust Member ID and date of birth to verify your identity.

Please Note: You have to enter your complete ID (example:00000123400). The additional 00 after the Trust ID is needed to continue.

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Fill out your personal information to register your account.

Once your account is created, you can download the MDLIVE app in the App Store or through Google Play.

Login and begin to see a doctor when you need one.

SUMMER 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG

5 THINGS YOU NEED TO KNOW ABOUT

3Dmammography

There is so much information out there today regarding screening mammography that it’s difficult to know what to do. And with the recent introduction of 3D mammography into the picture, now there’s one more thing to consider. So we thought we would try to help clear up the confusion and give you the facts about this new technology.

40% increase in Cancer Detection

Not all 3D is the Same

15% Decrease in false positives.

Are You Dense?

Need we say more? As a stand-alone statistic, this really says it all. 3D Mammography, or Digital Breast Tomosynthesis, is a breakthrough in breast cancer detection. When combined with standard 2D mammography, studies show up to a 40% increase in breast cancer detection as compared to using 2D mammography alone. This is a game-changer for women, especially those who have already been diagnosed with breast cancer and will need more frequent screening, and added peace of mind.

A false positive is when a study is interpreted as showing an abnormality when in reality the study was normal. Tomosynthesis is an especially effective screening technique for women with dense breast tissue, and has demonstrated a reduction in false positives by approximately 15 percent.

10% Decrease in subsequent imaging.

Because standard 2D mammography is not as accurate as 3D, patients are called back to conduct additional exams such as breast ultrasounds, breast MRI and breast biopsies. As a patient, when you get that call to say that you need to come back for further testing, it causes a great deal of stress and anxiety. 3D mammography has been shown to decrease these stressful subsequent exams by 10 percent.

When evaluating the different 3D technology, one brand stood out – the GE SenoClaire system. Only GE’s system delivers a screening mammogram with no more radiation than standard 2D mammography. Unlike the Hologic “Genius” system, GE’s SenoClaire 3D exam is conducted simultaneously with the 2D mammogram, so it delivers NO more radiation than your previous 2D digital mammogram, and only takes a few minutes more. In this case, LESS is definitely MORE!

Forty percent of women in the U.S. have dense breast tissue.

And dense breast tissue is the Achilles heel of standard digital mammography. Dense tissue shows up as white on a mammogram, as does cancer. 3D mammography overcomes this issue in the way that it creates the images. As the scanner sweeps over the breast in an arc, it takes the images (called slices) of the breast from all different angles, making it harder for cancer to hide. This greatly enhances our radiologists’ ability to detect abnormalities and identify suspicious structures in the breast more easily.

Still not sure if 3D Mammography is for you?

Don’t hesitate to call us with your questions, or get more information at: www.sdmi-lv.com/3Dmammogram. 3D mammography is available at all seven Steinberg Diagnostic Medical Imaging locations. Physician referral required. Call (702) 732-6000 to schedule yours today.

Sponsored by Steinberg Diagnostic Medical Imaging

FEATURES Referrals and Prior Authorizations:

Understanding the Importance & Difference of the Two CHANGES AND CLARITY The introduction of the Performance Plus Plan has brought many changes to how our participants access and utilize their benefits.

Some of these changes have, unfortunately, caused some confusion around the processes for prior authorizations and referrals.

While prior authorizations have always been part of the Trust’s medical plans, they are handled by your doctor and, therefore, often go unnoticed. Referrals, on the other hand, are both new to the plan and front-facing, which means they require your attention. The Trust realizes that clarity is needed on these two very different items in order to better assist our participants.

REFERRALS A referral is generated by your doctor as a notice of his/her determination that you need to see a specialist. For the Performance Plus Plan, the physician enters the referral in a program called par8o. Once the referral has been entered into par8o, the physician creates a paper copy for your personal records as confirmation. The purpose of the referral is to assist the Trust, physicians and specialists in tracking and monitoring your care. This helps to ensure that all of the professionals involved are properly communicating about your treatment; the end result being that your primary care physician has all essential information to manage your care effectively.

The Trust and its partners want you to know that referrals should never result in restricted care, only well-coordinated treatment.

If referrals ever result in a restrictive or slowed process for you, please contact the Healthcare Advocates for assistance at (855) 404-9355 or via e-mail at advocates@wellhealthqc.com.

PRIOR AUTHORIZATION All health plans have services and treatments available to participants that must first be authorized. These authorizations rarely require your involvement. Prior authorizations allow the Trust’s case managers to help coordinate your care and minimize your out-of-pocket costs by verifying that any procedures or treatments you receive are medically necessary.

As with referrals, the purpose of prior authorizations are never to restrict, but to properly manage care. If you run into challenges due to prior authorization, contact the Trust Service Team for assistance at (702) 794-0272 or via e-mail at serviceteam@ teachershealthtrust.org.

EFFECTIVE CARE FOR HEALTHIER LIVES The Trust understands that providing clarity on the processes that go into the healthcare for you and your family is essential. We encourage you to reach out to us whenever you need assistance with your plan benefits. Always remember that one of the keys to a healthier life is effective and managed care. Referrals and prior authorizations are simply tools designed to help with this goal.

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SUMMER 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG

here’s to health programs The Here’s To Health programs are designed for members with diabetes, asthma/COPD, heart health issues, or a high-risk pregnancy.

In order to receive the exclusive benefits for each program, you need to fill out the appropriate enrollment form which can be found on the Teachers Health Trust website.

In addition to the program specific benefits, you will also receive a $0 copay to see the appropriate in-network specialist of your choice. If you do not have a specialist, one can be recommended for you.

CONTROL IS THE GOAL

DIABETES MANAGEMENT PROGRAM BENEFITS • Glucometer (limit 1 per member/per year) • Test strips, lancets, syringes and needles • Educational resources covering the basics of diabetes care to more advanced instruction on teachershealthtrust.org • A $100 maximum per prescription, per month on out-of-pocket expenses for identified formulary diabetic medications (drug list available at teachershealthtrust.org)

MY BEST PREGNANCY

HIGH-RISK PREGNANCY PROGRAM BENEFITS • $0 copay to see your high-risk doctor • Printable handouts and resources available on teachershealthtrust.org • New mom gift • Support via email and/or phone with our My Best Pregnancy Perinatal Nursing team

BREATHE EASY

ASTHMA /COPD PROGRAM BENEFITS • $0 copay to see your high-risk doctor • Printable handouts and resources available on teachershealthtrust.org • Support via email and/or phone with our Breathe Easy team

HAVE A HEART

CARDIOLOGY PROGRAM BENEFITS • $0 copay to see your cardiologist • Printable handouts and resources available on teachershealthtrust.org • Support via email and/or phone with our Have a Heart team SUMMER 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG

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Services requiring prior authorization Certain procedures and services require prior authorization to evaluate the medical necessity and appropriateness of the service. Accredited medical and behavioral health organizations conduct these reviews for the Trust.

Regardless of what the reviewing organization recommends, it is always up to you and your doctor to decide what, if any, care you receive. In the event you and/or your Physician do not agree with the authorization decision that you receive, your Physician may appeal the decision to the reviewing organization by providing (in writing) additional information to support the initial request for authorization.

You should advise your Physician to obtain Prior Authorization on your behalf if the services require it. If Prior Authorization is not obtained, benefits for the service may be greatly reduced or not paid at all. Prior Authorization does not guarantee payment of benefits or determine what level of Plan benefits will apply.

MENTAL HEALTH/CHEMICAL DEPENDENCY Mental health/chemical dependency services are covered under the Performance Plus Plan. Services obtained by mental health/chemical dependency providers, such as counselors and psychiatrists, do not require a referral from the participant’s PCMH physician, but prior authorization for medical necessity from Human Behavior Institute (HBI) applies. See below.

Counselor Visits (after 24 sessions) Detoxification Medications Group Therapy Visits (after 24 sessions) Inpatient Care Mental Health NP Visits Partial Hospitalization Psychiatric Visits Psychosocial Rehabilitation and Autism Services Residential Treatment Therapist Visits (after 24 sessions) MD Visits Obtain prior authorization by calling HBI: (800) 441-4483 or (702) 248-8866. Should be obtained at least 48 hours prior to service.

MEDICAL SERVICES Air Ambulance Blepharoplasty Botox Breast Surgery Continuous Glucose Monitoring Devices Cosmetic Surgery CT Scans Dialysis Durable Medical Equipment (over $500) Endoscopy Extended Network Benefit Genetic Testing Hernia Repair Home Health Care Hospice Care Hyperbaric Oxygen Therapy Inpatient Admissions IV Infusions MRI and MRA Nerve Conduction Studies/ EMG Oral Appliance for Sleep Apnea Out-of-Network Laboratory Outpatient Perinatology Pain Management (Nerve Blocks) PET Scans Sclerotherapy Skilled Nursing Facility SPECT Cardiolyte Testosterone Pellets Insertion Transplant and Follow-up Transplant Services Virtual Testing Obtain prior authorization from TriStar Managed Care: Phone: (702) 832-4658 or Toll Free at (844) 586-2244 Fax: (702) 847-7690 or (562) 506-0340 E-mail: authorizations@wellhealthqc.com

SUMMER 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG

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TEACHERS HEALTH TRUST 2950 E. Rochelle Ave. Las Vegas, NV 89121 (702) 794–0272 or (800) 432–5859 teachershealthtrust.org