Perspectives summer fall 2017 by Valley Health Plan

s e v i t c e p s Per

r e t t e l s w e N r e b m Me

A Message from Dolly C. Goel, MD

Member Services Unit-Based Team.................................7 MDLIVE - New Telehealth Benefit.....................................8 Important Information on the VHP Website....................10 Provider Directory..............................................................11 Coordination of Benefits...................................................12

Table of Contents

Valley Health Plan is proud to partner with and support the East San JosĂŠ PEACE (Prevention Efforts Advance Community Equity) Partnership and the State of California to address racial and health inequities by preventing youth, family, and community violence and trauma. The VHP Chief Medical Officer PEACE Partnership identifies, prioritizes, and funds existing and new violence prevention strategies through a new infrastructure model, an Accountable Community for Health. It is one of six pilots in California supported by the California Accountable Communities for Health Initiative (CACHI). We are very excited to be part of a new model of care that promotes and supports safer and healthier communities.

Health Education Programs & Events..............................2 - Weight Watchers - Free Member Wellness Day - Personal Health Assessment (PHA) - Nutrition Talk Series - Adult Diabetes Prevention Program - Breast Cancer Awareness Campaign

Out-of-Network Urgent Care Services............................12 VHP Advisory Board ........................................................13 Change of Address...........................................................13

Member Rights and Responsibilities...............................14 New Autism Care Management Program.......................17

CarePoint - Chronic Health Condition Program.............17

How to Contact the Utilization Management Dept........18

New Technology Review...................................................18 Authorization Review & Criteria Decision Making Process.................................................................18 VHP Quality Management Team Updates......................19 Protected Health Information...........................................20 Affirmative Statement About Financial Incentives........21 Speaking the Language of Health..................................21 Pharmacy Network Information......................................22

017 2 l Fal | r me m Su

Health Education Programs & Events Weight Watchers®

Valley Health Plan is committed to helping you reach your weight-loss goals and improve your overall health by offering a discounted price on the Weight Watchers® offerings listed below. By enrolling through Valley Health Plan’s program, members can take advantage of a subsidy reducing the cost of membership by more than 50% of the regular membership price.

Black-and-White Summer Bean Salad

SmartPoints value

PREP TIME: 20 min | SERVINGS: 4

To enroll today, or to learn more visit: www.valleyhealthplan.org

Click

Ingredients

Weight Watchers Program at a Glance:

1. Eat better with the Smartpoints™ Plan Smartpoints steer you towards less sugar, less saturated fat, and more protein. Every food is on the menu - it’s your choice!

2. Shift Mindset because if you THINK different you’ll act

differently. A shift in your mindset will help you gain greater selfawareness to make different choices, so you can achieve your goals and become a happier, healthier you.

3. Move more with Fitpoints™ You get a personalized fitness goal to aim for and earn Fitpoints for the activities you do - all movements count.

1 cup(s) canned white beans, drained and rinsed 1 cup(s) canned black beans, drained and rinsed 1 large

fresh tomato(es), diced

1 small

uncooked onion(s), diced

1 rib(s)

uncooked celery, diced

2 Tbsp

white wine vinegar, or red wine vinegar

3 Tbsp

fresh parsley, Italian-variety, or basil, minced.

1/8 tsp

table salt, or more to taste

1/8 tsp

black pepper, or more to taste

Instructions In a large bowl, combine beans, tomato, onion and celery. Gently stir in vinegar and sprinkle with parsley or basil; season to taste with salt and pepper. Yields about 1 cup per serving. Notes This recipe is fresh-tasting, quick and flavorful. Keep it basic as written or add fresh lemon or lime juice, capers and/or olive oil (any changes could affect the recipe’s SmartPoints value).

www.valleyhealthplan.org 3

FREE VHP Member Wellness Day Coming this Fall! Join us for a FREE VHP Member Wellness Day.

WHEN: Saturday, September 30, 2017 TIME: 10:00am – 3:00pm WHERE: Timpany Center, 730 Empey Way, San Jose

The YMCA Nutrition Talk Series will include a discussion and a demonstration on how to prepare nutritious foods. Each class will offer a different topic. Classes will be held Saturday mornings from 9:30am-11:00am at a YMCA in the San Jose area (exact location, times and topics are listed below).

Some of the things you can expect from this fun-filled day: • Health & Wellness information • Flu Shots • Biometric Screenings • Zumba Demonstration (Blood pressure, cholesterol, glucose) • Member Goodie Bag Pre-register online or call 408.885.3490

Boosting Your Immune System Before Cold and Flu Season Saturday, September 9, 2017 (9:30-11:00am) YMCA of Silicon Valley - Association Office 80 Saratoga Ave, Santa Clara, CA 95051

IMPORTANT: Your VHP ID card will be required to attend this event.

• Discuss which foods help fight disease and which ones inhibit your immune system. • Let’s make soup: The YMCA will provide the basic ingredients. Please bring your favorite soup ingredient and you will make a delicious pot of soup to enjoy together.

Personal Health Assessment (PHA) VHP is partnering with Cerner Wellness to provide members with an online wellness portal. The easy 15-minute Personal Health Assessment (PHA) will help you understand your current health status. Visit vhp.mycernerwellness.com to access the online wellness portal, take your PHA, and start earning Wellness Rewards! • Get your personalized PHA results and wellness recommendations. • Sync your Fitbit and mobile app to conveniently track your exercise and fitness. • Access exercise video clips and online health education workshops. • Track your daily food and water intake. • Chat with certified personal trainers and registered dietitians about your health questions and try healthy recipes and specialized meal plans to keep you motivated. For more information, contact the Health Education Department by email at healtheducation@vhp.sccgov.org or call 408.885.3490.

Level 2

Level 3

Healthy Holiday Survival Guide Saturday, December 9, 2017 (9:30-11:00am) South Valley Family YMCA 5632 Santa Teresa Blvd., San Jose, CA 95123 • Discuss diet tips and strategies to prevent weight gain during the holidays. • Prepare healthy and delicious appetizers that you can serve at your holiday party. Healthy Grains Saturday March 10, 2018 (9:30-11:00am) East Valley Family YMCA 1975 S. White Road, San Jose, CA 95148 • Learn how to prepare healthy grains such as quinoa, barley, and millet. • Discuss why grains are an important part of our diets and their health benefits.

Track your wellness points and earn rewards!

Level 1

Nutrition Talk Series & Cooking Demonstrations

Level 4

6 Simple Steps to a Healthy Dinner Saturday, June 16, 2018 (9:30-11:00am) YMCA of Silicon Valley - Association Office 80 Saratoga Ave., Santa Clara, CA 95051 • No time to cook dinner tonight? This cooking demo will make preparing healthy meals fast and simple. • Tips for preparing for your grocery shopping and how to save money.

Workout Towel

Fruit Market Bag

Hat

T-Shirt

CHOOSE HEALTH, LIVE WELL! 4 Perspectives | Summer - Fall 2017

www.valleyhealthplan.org 5

Adult diabetes

Prevention Program (DPP) VHP is partnering with the YMCA to offer a FREE 16-week Diabetes Prevention Program. This program includes a FREE (3 month) YMCA full gym membership, while you are participating in the program. The YMCA’s Diabetes Prevention Program can help you make lifestyle changes to improve your overall health and well-being, while lowering your risk of developing this disease. This program is focused on helping high risk individuals prevent developing type 2 diabetes. For eligibility questions and to register, please contact the YMCA Diabetes Prevention Program at ymcadpp@ymcasv.org or 408.351.6440.

bREAST cANCER aWARENESS cAMPAIGN Get Screened! NEW WELLNESS CLASS! VHP is launching a Breast Cancer Awareness Campaign to educate and get the word out about the disease that affects 1 of 8 women in their lifetime. By taking preventive measures, breast cancer can be detected in the early stages which can help beat the disease. Take time for monthly breast self-exams, schedule regular clinical breast exams, and get a mammogram.

VHP members who get a mammogram between 07/01/2017 – 06/30/2018 will receive a reward for their prevention efforts. VHP will run periodic reports that will show that a member was screened and a reward will be sent. 6 Perspectives | Summer - Fall 2017

Member Services Unit-Based Team Valley Health Plan Member Services UBT has been working to make the phone experience better for members. Valley Health Plan Member Services followed the lead of Santa Clara Valley Health & Hospital System to form their own Unit-Based Team (UBT). Work started on January 1, 2017 to reduce the number of caller hang ups. It had been 10% of calls and they wanted to get it to 7% of calls. By March 2017, the abandoned call rate dropped below their 7% goal! The team achieved this goal through constant communication within the department and implementing changes when they saw opportunities. For example, a change was made for when a VHP member is calling for information that is not readily available. Instead of holding for a long time as the information is tracked down, the member can now get a call back when the information is available. This improves the member experience and frees up staff to answer other calls. Since the launch of the collaborative effort, the team’s leads, supervisor, and department sponsor have worked together to make improving the caller experience achievable. Together, they selected the motto, “You call, we care.” The team is commited to making sure changes have longevity and benefit, not only current customers, but future ones as well. All staff are encouraged to participate and offer new ideas. “It has been an all-around group effort and we all want this to be successful. We want to be the first choice for Santa Clara County residents when they are looking for a health plan,” Stacy Johnson, Member Services Representitive.

The UBT encouraged department staff to participate and bring fresh ideas. They are now working with their vendor to add an option for callers to leave messages. The goal is to further reduce the caller hang-up rate. “Being part of this UBT project has been a great learning experience and it’s been incredible to see everyone pulling together to achieve a common goal. The ideas and processes we are implementing will stay with us long after the UBT project is over. I can’t emphasize enough - we strive to be the plan of first choice,” Martha Cisneros, Member Services Supervisor. The below graphic shows how the Member Services team worked together to make significant improvements.

Decreasing answering speed times from: 2 mins.

60 sec.

Decreasing caller wait times from: 18 mins.

> 10

Decreasing abandonment rates from: 10%

> 7%

Decrease call/hold research times from: 7 mins.

> 5 mins.

www.valleyhealthplan.org 7

VHP’s New Telehealth Benefit with MDLIVE VHP is excited to announce a new telehealth benefit with MDLIVE for urgent care, nonemergency primary care, and behavioral health visits. For emergencies, call 911 or go to the closest Emergency Room. Members now have 24/7/365 access to board-certified doctors via phone, secure video, or the MDLIVE App—from anywhere! With an average call-back time of less than 10 minutes, MDLIVE can have you feeling better faster, without the need to leave your home or office. Plus, if the doctor feels you need a prescription, they can electronically send it to the closest VHP plan pharmacy.

Avoid the wait.

MDLIVE Mobile App 4.0

Quality Care Now Goes Where You Do.

Evite las esperas.

Your life is 24/7. Now your doctor is too.

Su vida está disponible las 24 horas del día, los 7 días de la semana. Ahora su médico también lo está.

Welcome to MDLIVE! You're eligible, so activate your account today. Consult with a board-certiﬁed doctor by phone, secure video, or MDLIVE App— anytime, from anywhere. Licensed therapists also available by appointment via secure video

Active MDLIVE hoy mismo.

Average wait time is less than 10 minutes to see a state-licensed, board-certiﬁed physician averaging years of practice Consulte con un médico 15 certiﬁcado por la experience Junta Estadounidense de Especialidades Médicas, por teléfono, vídeo seguro, o la Aplicación MDLIVE—en cualquier momento, desde cualquier parte Your family members are also eligible, and we have pediatricians available 24/7 Tiempo promedio de espera es de menos de 10 minutos

ACTIVATE

your account online or by phone. No lo deje para después.

¡ACTIVE!

Download the MDLIVE App

Non-emergency conditions we treat:                  

Ailing at work? Sick on vacation? Grounded in bed?

Acne Behavioral Health Allergies  Addictions Cold / Flu  Bipolar disorders Constipation  Child and adolescent issues Trastornos que tratamos que no Cough son de emergencia: Depression Diarrhea  Eating disorders EarAcné problems ■ ■ Náusea / Vómitos  Gay/Lesbian/Bisexual/ Transgender issues Fever* ■ Alergias ■ Picaduras  Grief and lossde insectos Headache

The MDLIVE Mobile App 4.0 makes connecting with doctors and behavioral health counselors fast, easy, and convenient.

 Life changes del oído Insect bites ■ ■ Problemas Conjuntivitis  Men’s issues Nausea / Vomiting ■ Diarrea ■ Problemas  Panic disordersrespiratorios Pink eye  Parenting issues ■ ■ Rash Dolor de cabeza Problemas urinarios /  Postpartum depression Infecciones urinarias Respiratory problems  Relationship and marriage issues ■ Dolores de garganta Sore throats  Stress ■ Tos ■ Urinary problems / UTI* Erupciónes  Trauma and PTSD ■ Vaginitis Vaginitis  Women’s issues ■ Estreñimiento  And And more ■ Ymore más ■ Fiebre e-prescriptions can be sent to your local pharmacy (if required) for medical conditions.

■ 24/7/365 access to board-certiﬁed doctors via phone, computer, or app ■ Video sessions with licensed behavioral health counselors (by appointment) ■ One of the nation’s largest telehealth networks ■ Private, secure, and conﬁdential visits, from anywhere ■ Connect instantly with MDLIVE Assist

MDLIVE cannot prescribe medication for behavioral health conditions.

■ Gripe / Resfriado

Recetas-electrónicas pueden ser enviadas a la farmacia de su localidad (si fuese requerido) para problemas de salud.

MDLIVE.com/ VHP 1.888.467.4614

MDLIVE.com/company +1 (XXX) XXX XXXX

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*MDLIVE physicians may not treat any children with urinary symptoms. Parents/guardian will be required to complete a diﬀerent medical history disclosure form for children under the age of 36-months prior to making an appointment with an MDLIVE physician. Children under 36 months who present with fever must be referred to their pediatrician (medical home), child-friendly urgent care center or emergency department for clinical evaluation and care. MDLIVE does not provide any healthcare services and is not an insurance product or a prescription fulﬁllment warehouse. MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Contents in this material are not a substitute for professional healthcare advice, diagnosis or treatment. MDLIVE healthcare professionals reserve the right to deny care for potential misuse of services. MDLIVE interactive audio consultations with store and forward MDLIVE noare reemplaza médico primario. MDLIVE noonly, es unwhile seguro ni un almacén deare distribución medicamentos opera sujeto a regulaciones estatales for y podría no and estar technology availableal24/7/365 for medical services video consultations available de during the hours ofrecetados. 7 am to 9 MDLIVE pm 7 days a week or by scheduled availability medical disponibleservices. en algunos estados. no garantiza que se emitirá una receta. MDLIVEInc. no and receta sustancias controladas por la Administración el Control deofDrogas (DEA, por sus siglas en behavioral MDLIVE andMDLIVE the MDLIVE logo are registered trademarks of MDLIVE, may not be used without written permission. Forpara complete terms use visit inglés), fármacos no terapéuticos y algunos fármacos que pueden ser dañinos por su potencial de abuso. Los médicos de MDLIVE se reservan el derecho de denegar la atención debido a la www.mdlive.com/pages/terms.html posibilidad de uso indebido de los servicios. Las consultas de audio interactivas de MDLIVE con tecnología de almacenamiento y reenvío están disponibles las 24 horas del día, los 7 días de la © 2016 MDLIVE, V.101716están disponibles de 7 a.m. a 9 p.m., los 7 días de la semana, o por disponibilidad acordada. MDLIVE y el logotipo de MDLIVE son marcas regissemana, los 365Inc. díasAll delrights año; reserved. las videoconsultas

Descargue la Applicación MDLIVE

mdlive.com/getapp

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No smartphone? No worries!

Activate your account using a computer or phone

MDLIVE.com/VHP 1.888.467.4614

Copyright © 2017 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Medical consultations are available by interactive audio on-demand 24/7/365 or by video 7 days per week from 7am EST to 9pm EST or by scheduled availability. Behavioral consultations are by scheduled availability. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://welcome.mdlive.com/terms-of-use/. V. 052217 MCR-411 10456

All visits are the same cost as an in-person doctor visit. For questions, please call MDLIVE at 1.888.467.4614 (toll-free). Visit www.MDLIVE.com/VHP and register today!

tradas de MDLIVE, Inc. y no se pueden usar sin permiso previo por escrito. Para conocer todos los términos y condiciones de uso visite www.mdlive.com/pages/terms.html 120115 © 2016 MDLIVE, Inc. All rights reserved. V.42716

8 Perspectives | Summer - Fall 2017

www.valleyhealthplan.org 9

IMPortant INFORMATION on the VHP Website VHP would like to remind you that our website includes important and helpful information. Visit www.valleyhealthplan.org to view and/or download information about the following topics. You can also contact Member Services at 1.888.421.8444 (toll-free) if you need assistance. • Quality Improvement Program including goals, processes, and outcomes as related to care and service. • Case Management Program and how you or your caregiver may self-refer to the Program. • Disease Management Programs and how you may self-refer to the Programs. • How to contact utlization management staff if you have questions about how we manage care and services and the toll-free number to call to contact staff. • Availability of TDD/TTY services. • Policy prohibiting financial incentives for utilization management decision-makers. • Description of the availability of an independent external appeals process for utilization management decisions made by VHP. • Member rights and responsibilities statement. • Benefits and services included in, and excluded from, coverage. • Copayments and other charges for which you are responsible. • Restrictions on benefits that apply to services obtained outside VHP system or service area. • Pharmacy procedures and coverage of drugs including copayments; VHP’s drug list along with restrictions and preferences; how to use our pharmacy procedures; an explanation of limits and quotas; how to receive coverage for non-formulary drugs and an explanation of how practitioners can provide information to support an exception; and VHP’s processes for generic substitution, therapeutic interchange, and 10 Perspectives | Summer - Fall 2017

step-therapy. • Copayments and other charges for which you are responsible. • Restrictions on benefits that apply to services obtained outside VHP system or service area. • Language assistance to talk with us about how we manage care and services or to obtain information about benefits, access to services, and other issues. • How to submit a claim for covered services. • How to obtain information about network practitioners and the professional qualifications of practitioners, including specialty, medical school attended, residency completed, and board certification status. • How to obtain primary care services, including how to choose and access a primary care practitioner. • How to obtain specialty care and behavioral health services and hospital services. • How to obtain care after normal office hours. • How to obtain emergency care, including VHP’s policy on when to directly access emergency care or use 911 services. • How to obtain care and coverage outside of VHP’s service area.

Tools: In the health and wellness section, there is additional information and tools to help you better understand what you can do to improve your health. Provider Directories: Our Physician and Hospital Directories allow you to select a physician or hospital that best meets your needs. You can search for a physician by specific characteristics such as gender or language spoken. You can search for a hospital by location and name. Personal Health Assessment (PHA): You can help manage your health online. A personal health assessment is available and helps you assess your current health and determine risks. It also allows you to track your progress in improving behaviors and lets you know when to obtain preventive services.

If you need any assistance, please call the Member Services Department at 1.888.421.8444 (toll-free). They can print and mail any information from our website if you do not have access. The website has the most recent information, benefits, services, and drug coverage.

Provider Directory Valley Health Plan or a delegated entity (such as a hospital or medical group) credentials all physicians in the network and verifies the background and education of all practitioners. The Provider Directory provides general information on all practitioners. If you would like specific information on a physician such as the medical school attended, residency completed, or board certification status, please contact Member Services at 1.888.421.8444 (toll-free).

• How to voice a complaint. • How to appeal a decision that adversely affects coverage, benefits or your relationship with VHP. • How VHP evaluates new technology for inclusion as a covered benefit. www.valleyhealthplan.org 11

Coordination of Benefits

VHP Advisory Board

Do you or any of your eligible dependents have health insurance coverage with another health plan or insurance agency? If so, you are required to notify Valley Health Plan (VHP) of such coverage in the case where medical claims may need to be coordinated for payment.

What is the VHP Advisory Board? Advisory Board members may assist Valley Health Plan (VHP) in establishing Public Policy. PublicPolicy means acts performed by VHP and its employees to assure the comfort, dignity, and convenience of Members who rely on VHP providers for services. The findings and recommendations of this Public Policy Committee or Advisory Board are regularly reported to VHP’s governing body. A minimum of 51% of the VHP Advisory Board must be VHP Members.

VHP does not coordinate benefits with other health insurance companies for services provided by non-VHP providers or for services that have not been pre-authorized by VHP. If you or your eligible dependents have other health insurance, please call VHP Member Services at 1.888.421.8444 (toll-free). Or, you can fax a copy of the insurance ID card(s) to VHP Member Services to 408.885.4425. Please include the subscriber’s name and a daytime phone number. For more detailed information, see VHP’s Combined Evidence of Coverage & Disclosure Form – Member Handbook or call VHP Member Services at 1.888.421.8444 (toll-free).

Interested in Serving on the VHP Advisory Board? If you would like more information, please call Member Services at 1.888.421.8444 (toll-free), Monday through Friday, 9:00am to 5:00pm and ask to speak to Martha Cisneros, Member Services Supervisor.

Out-of-Network Urgent Care Services

Change of Address

If it is necessary to receive urgent care services outside of the VHP service area and it is during VHP business hours (M–F, 9am–5pm), please call Member Services at 1.888.421.8444 (toll-free).

Is Your Information Up-to-Date? It is very important that VHP has your correct address and phone number on file. We want to make sure you receive our important mailings about additions or changes to benefits, providers/networks, or tools to help you maintain your overall health.

A Member Services Representative can assist you by either directing your call to a VHP nurse for advice and/or by obtaining approval to seek services with an out-of-network urgent care provider. If after business hours, please call our 24/7 Nurse Advice Line and they can direct you to the closest medical facility. When seeking services, present your VHP ID card as well as another form of photo ID. Except in the case of an urgent medical need or emergency services, prescriptions must be filled at a VHP Network Pharmacy location unless pre-authorized.

12 Perspectives | Summer - Fall 2017

All follow-up care for out-of-network urgent care services must be provided by your VHP PCP unless pre-authorized by Valley Health Plan. • Apollo Criteria • InterQual (IQ) • Medi-Cal • Medicare CMS regulations • Med Impact, Harvard Pilgrim medical necessity criteria, and/or Epocrates and MicroMedex • Milliman Care Guidelines • National specialty boards, published guidelines, clinical studies

Valley Health Plan can provide copies or paraphrase the section when copyright restrictions apply, or the criteria applicable to the specific procedure or conditions requested.

If your information has changed, please call the number that applies to your coverage: Employer Group Plan Members Human Resources Department

Covered California Plan Members Covered California Service Center 1.800.300.1506

Individual & Family Plan Members Valley Health Plan Member Services 1.888.421.8444 (toll-free), Option 3

For more information, you can contact the Utilization Management Department at 1.888.421.8444 (toll-free), Monday – Friday, 9:00am – 5:00pm PST.

www.valleyhealthplan.org 13

Member rights and Responsibilities A member has the right to: 1. Exercise these rights without regard to race, disability, sex, religion, age, color, sexual orientation, creed, family history, marital status, veteran status, national origin, handicap, or condition, without regard to your cultural, economic, or educational background, or source(s) of payment for your care; 2. Be treated with respect and recognition regarding your dignity and your right to privacy; 3. Expect health care providers (doctors, medical professionals, and their staff) to be sensitive to your needs; 4. Be provided with information about VHP, its services, Plan Providers, and member rights and responsibilities; 5. Know the name of the Primary Care Physician who has primary responsibility for coordinating your health care and the names and professional relationships of other Plan Providers you see; 6. Actively participate in your own health care, which, to the extent permitted by law, includes the right to receive information so that you can accept or refuse recommended treatment; 7. Receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse this course of treatment or procedure. Except for Emergency Services, this information will include a description of the procedure or treatment, the medically significant risks involved, alternative courses of action and the risks involved in each the name of the Plan Provider who will carry out the treatment or procedure; 8. Full consideration of privacy concerning your course of treatment. Case discussions, consultations, examinations, and treatments are confidential and should be conducted discreetly. You have the right to know the reason should any person be present or involved during these procedures or treatments; 14 Perspectives | Summer - Fall 2017

9. Confidential treatment of information in compliance with state and federal law including HIPAA (including all communications and medical records) pertaining to your care. Except as is necessary in connection with administering the Agreement and fulfilling State and federal requirements (including review programs to achieve quality and costeffective medical care), such information will not be disclosed without first obtaining written permission from you or your authorized representative; 10. Receive complete information about your medical condition, any proposed course of treatment, and your prospects for recovery in terms that you can understand; 11. Give informed consent unless medically inadvisable, before the start of any procedure or treatment; 12. Refuse health care services to the extent permitted by law and to be informed of the medical consequences of that refusal, unless medically inadvisable; 13. Readily accessible and ready referral to Medically Necessary Covered Services; 14. A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage; 15. A second medical opinion, when medically appropriate, from a Plan Physician within the VHP Network; 16. Be able to schedule appointments in a timely manner; 17. Reasonable continuity of care and advance knowledge of the time and location of your appointment(s); 18. Reasonable responses to any reasonable requests for Covered Services; 19. Have all lab reports, X-rays, specialist’s reports, and other medical records completed and placed in your files as promptly as possible so that your Primary Care Physician can make informed decisions about your treatment;

A member has the responsibility to: 1. Provide complete & accurate information (to extent possible) that VHP and its practitioners/ 21. Request and expedited change of a provider providers need in order to provide care. Inform due to medical necessity; practitioner/provider about any health issues, 22. Review your medical records, unless medications, and allergies. This information medically inadvisable; should also include living will, medical power of attorney, or other directive that could affect 23. Be informed of any charges (Co-payments) care; associated with Covered Services; 2. Follow plans and instructions for care that you 24. Be advised if a Plan Provider proposes have agreed to with your practitioner; to engage in or perform care or treatment involving experimental medical procedures, 3. Behave in a manner that doesn’t interfere with and the right to refuse to participate in such your Plan Provider or their ability to provide procedures; care; 20. Change your Primary Care Physician;

25. Leave a Plan Facility or Hospital, even against the advice of Plan Providers; 26. Be informed of continuing health care requirements following your discharge from Plan Facilities or Hospitals; 27. Be informed of, and if necessary, given assistance in making a medical Advance Directive; 28. Have rights extended to any person who legally may make decisions regarding medical care on your behalf; 29. Know when Plan Providers are no longer under a contractual arrangement with VHP; 30. Examine and receive an explanation of any bill(s) for non-Covered Services, regardless of the source(s) of payment;

4. Safeguard the confidentiality of your own personal health care as well as that of other Members; 5. Accept fiscal responsibility associated with non-Covered Services. Covered Services are available only through Plan Providers in your VHP Network (unless such care is rendered as Emergency Services or is authorized); 6. Cooperate with VHP or a Plan Provider’s third party recovery efforts or Coordination of Benefits; 7. Participate in your health care by scheduling and keeping appointments with Plan Providers. If you cannot keep your appointment, call in advance to cancel and reschedule;

31. Voice complaints or appeals about VHP or the care it provides;

8. Report any changes in your name, address, telephone number, or your family’s status to your employer, Covered California, and a VHP Member Services Representative; and

32. File a Grievance without discrimination through VHP or appropriate State or federal agencies;

9. Understand your health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.

33. Know the rules and policies that apply to your conduct as a Member; 34. Make recommendations regarding Valley Health Plan’s member rights and responsibilities policy; and 35. Participate with practitioners in making decisions about your health.

www.valleyhealthplan.org 15

CAREPOINT New Chronic Health Conditions Program VHP is excited to roll out the new CarePoint program to help members with chronic health conditions get on the road to better health. CarePoint is designed to provide help and support to those facing chronic and ongoing diseases. This program is not focused only on a specific condition like diabetes or asthma. Instead, CarePoint uses advanced analytics to identify things that may be impacting your health, like missing medications or not visiting the doctor when it’s needed. The CarePoint team will reach out to you and provide ideas, tips, and resources to help you solve those things that are keeping you from your best health. The program will pair you with the right care manager based on your health challenges. Whether it’s a registered nurse, a social worker, or a community resource, our experienced care team staff will be here to help you.

The team will customize your communications, so if you prefer texting instead of phone calls, or would rather communicate with your care manager through secure emails, we’ve got you covered. This program is designed to give you an extra boost by bringing in your family, caregivers, and friends who are supporting you on your health journey. You can choose who to add to your program so you’re supported the way you need. CarePoint also has a state-of-the-art smartphone app. This private social network is available for you and whomever else you want to include. The app is fun to use and can provide reminders and information customized just for you. For information about the new CarePoint program, please call VHP Member Services at 1.888.421.8444 (toll-free).

NEW AUTISM CARE MANAGEMENT PROGRAM for Families Living with Autism Spectrum Disorder VHP is launching a no cost, innovative Autism Care Management Program designed to support families taking care of a child with Autism Spectrum Disorder (ASD).

living with a developmental disorder. The care managers serve as an extension of the health care team, ensuring families get additional, coordinated support that aligns with the family’s other doctors and specialists.For families with a child with ASD, a care manager will reach out to you by telephone to schedule an assessment.

Program care managers work with parents to deliver one-on-one support, prioritize care issues, and address any barriers that are limiting the family or their child from receiving If you would like to find out more about our new necessary health care services. The care ASD Care Management Program, please call manager is the primary point of contact for 1.888.863.7586 (toll-free). families and can answer questions or address problems families need assistance with to make sure their child’s health care needs are met. The care managers are ASD specialists with numerous years of experience, and understand the many challenges of caring for a child 16 Perspectives | Summer - Fall 2017

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How to Contact the Utilization Management Department The Utilization Management (UM) Department evaluates and determines coverage for, and appropriateness of, medical care services, providing assistance to Members and providers to ensure appropriate use of resources. To contact the UM Department to receive information about the process or status of authorizations and referrals, call Member Services at 1.888.421.8444 (toll-free), Monday through Friday, 9:00am – 5:00pm PST or email at Memberservices@vhp.sccgov.org. Language services are available at any time, for the hearing and speech impaired, call the California Relay Service (CSR) by simply dialing 711 or the 800 CRS number of your modality. After business hours, weekends, and on holidays, all calls will be returned on the next business day.

New Technology Review Valley Health Plan has a rigorous process in place to evaluate new technologies that are being developed such as for drugs, medical and behavioral health procedures, and medical devices. VHP’s Utilization Management Committee and Pharmacy & Therapeutics Committee, under the supervision of the VHP Chief Medical Officer, review many areas to make sure that these are safe and effective prior to covering the new technology as a benefit. VHP uses scientific literature, peer-reviewed journal articles, information from medical societies, and government agencies such as the Food and Drug Administration (FDA) to make decisions. New technology that has not been initially approved because its safety or effectiveness has not been demonstrated can be reviewed in the future when more information becomes available.

Authorization Review and Criteria and Decision Making Process Valley Health Plan (VHP) ensures that medical necessity decisions affecting the health care of Members are made in fair, impartial and are consistent by using objective measurable criteria based on reasonable medical evidence. Authorization requests are reviewed by the VHP Utilization Management (UM) staff to determine the medical necessity for requested services. VHP uses the following criteria sets to assist in this determination: ––Apollo Criteria ––Milliman Care Guidelines ––Med Impact, Harvard Pilgrim medical necessity ––InterQual (IQ) ––National specialty boards, criteria, and/or Epocrates published guidelines, ––Medi-Cal and MicroMedex clinical studies ––Medicare CMS regulations VHP can provide copies or paraphrase the section when copyright restrictions apply, or the criteria applicable to the specific procedure or conditions requested. For more information, you can contact the UM Department at 1.888.421.8444 (toll-free), Monday through Friday, 9:00am – 5:00pm PST.

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VHP QUALITY Management Team Updates The Quality Management (QM) Program is centered on VHP’s vision, mission, and values. The scope and content of the quality management program represents the entire VHP delivery system. The teams monitoring and evaluation activities involve a planned, systematic, and ongoing process to improve the quality of care and service our members receive. QM Program Goals: VHP’s QM Program goals are to ensure that our members receive high quality care and service wherever they access care. The team accomplishes this by ensuring standards and regulations are followed by care givers and addressing member satisfaction concerns. Our monitoring includes the medical and behavioral health services provided to our members. The team is also focused on identifying opportunities for performance improvement throughout the care delivery system. Some of the highlights for 2016 were: 1. Coordination of Care - The annual Consumer Assessment of Healthcare Provider Systems (CAHPS) survey revealed 79.25% percent of members reported their personal doctor “always and usually” were informed about care from other practitioners. 2. VHP’s QM Department completed a quality project to seek input from our members receiving behavioral healthcare services. Overall, members reported they were satisfied with their behavioral health experience at 77.78% (agree and strongly agree). 3. A quality project revealed 100% of members who participated in the Care Management program, those identified with depression and diabetes, had a treatment plan and followup care in place to meet their needs. 4. VHP and Santa Clara Valley Medical Center (SCVMC) have worked hard over the last year to ensure you received a timely appointment with a specialist. As a result of this work, we have noted member concerns related to appointment access at SCVMC has dropped by 59.90% by the year’s end.

Some of the various quality projects planned by the QM team for 2017:

• Monitoring the MDLIVE telehealth activities and performance; • Unit Based Teams (UBT) performance improvement projects; • Taking actions and re-measuring performance for continuity and coordination of care between primary care physicians and other practitioners; • Completing a follow-up survey to assess members’ satisfaction with behavioral health services experience; and • Monitoring the new condition management program.

5. VHP and Navitus are working hard to ensure that medications are being delivered to you in a safe manner by reviewing your drug usage throughout the year and taking the appropriate action to notify your provider(s) of any concern with the medications you are taking. Overall, the QM team is excited with the planned activities for this year and are continuously looking for opportunities for performance improvement which will result in an excellent customer experience. VHP is implementing a new software program that identifies members eligible for certain services. This will enable VHP to notify members of available benefits and services. This is being done with the goal of improving the healthcare you receive. When it comes to member satisfaction, have you heard of Survey Monkey? VHP is now using the easy-to-use survey tool for member feedback. www.valleyhealthplan.org 19

Protected Health Information

Valley Health Plan does not share your health information with anyone without your authorization, unless we are permitted to do so by law. We understand that information about you and your health is confidential and personal. We are committed to protecting health information about you. We create and maintain a record of the care and services you receive through Valley Health Plan (VHP). We need this record to provide you with quality care and to comply with certain legal requirements. We are required by law to: • make sure that Protected Health Information (PHI) that is linked to you is kept private and confidential (with some exceptions), • give you a Privacy Notice about our responsibilities and privacy practices about your PHI; and • follow the terms of the Privacy Notice that is currently in effect.

Unless permitted by law, VHP will not use or share your PHI unless you have signed an authorization form that allows us to do so. You have the right to cancel the permission by requesting it in writing, except if we have used or shared your PHI when you first gave us permission to do so. The law limits how we can use and disclose some PHI related to treatment of drug and alcohol abuse, HIV infection, and mental illness. VHP may use, share or disclose your PHI when necessary as required by law and for treatment, payment, and other health care operations. You may elect to share your PHI information with an authorized representative such as a friend, family member or anyone you choose. For this type of sharing to happen, you must complete “The VHP Authorization for use/or disclosure of Protected Health Information” form. This form will be placed in your file and VHP will follow your instructions on what information to share. All members 18 years of age or older wishing to share their PHI, must complete this form. For a copy of this form, you can visit the VHP website at www.valleyhealthplan.org/sites/m/ mm/FormsResources/Pages/Resources.aspx or contact Member Services at 1.888.421.8444 (toll-free). 20 Perspectives | Summer - Fall 2017

You have the right to request that health care communications regarding sensitive services you receive be sent to an alternate address. These sensitive services can include, but are not limited to, services and treatment for mental health, pregnancy, sexually transmitted diseases, sexual assault, drug or alcohol treatment, HIV, and counseling. Members 12 years of age and older can request that Sensitive Service Confidential Communications be sent to an alternate address by contacting Member Services at 1.888.421.8444 (toll-free). The VHP website provides Members with information regarding their health coverage. When browsing the website, information may be collected and stored regarding your site visit such as the date, time, and number of visits. No identifying information is collected. The complete VHP Privacy Notice including a list of your rights and how VHP uses your health information can be found on the VHP website at: www.valleyhealthplan.org/Pages/PrivacyNotice. aspx If you have questions about this Privacy Notice, please contact Valley Health Plan Member Services at 1.888.421.8444 (toll-free), Monday – Friday, 9:00am – 5:00 pm.

Member Fraud Notice VHP is committed to providing Members with quality care. We encourage Members to notify VHP of any suspicious activity you might encounter while receiving care from one of our practitioners or providers. All complaints regarding fraud will be investigated. This will allow VHP to take the necessary actions to protect Members from unlawful activities. If you believe you’ve experienced or are aware of any fraud (waste or abuse of VHP health care resources), please contact Member Services at 1.888.421.8444 (toll-free), Monday – Friday 9:00am – 5:00pm.

Affirmative Statement About Financial Incentives Valley Health Plan affirms that: 1. Utilization Management (UM) decision making is based only on appropriateness of care and service and existence of coverage. 2. The Plan does not specifically reward practitioners or other individuals for issuing denials of coverage. 3. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

speaking the language of health

In Your Preferred Language English

Speaking the Language of Health…in your Preferred Language As a Member, Valley Health Plan can help you in your language at no cost. If you would like to talk to us or ask for information in your language, please call 1.888.421.8444 during business hours.

Spanish Le servimos…En el idioma de su preferencia Como miembro, Valley Health Plan puede ayudarle en su idioma sin costo alguno. Si desea hablar con nosotros o recibir información en su idioma, por favor llame al 1.888.421.8444 durante horas de oficina.

Vietnamese

Chúng Tôi Chăm Sóc Sức Khỏe Cho Qúy Vị… Bằng Ngôn Ngữ của Qúy Vị Là hội viên, Valley Health Plan có thể giúp qúy vị bằng ngôn ngữ của qúy vị miễn phí. Nếu qúy vị muốn nói chuyện với chúng tôi hoặc yêu cầu thông tin bằng ngôn ngữ của qúy vị, xin vui lòng gọi 1.888.421.8444 trong giờ làm việc.

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PharmacY nETWORK Information Valley Health Plan (VHP) offers our Members access to an extended pharmacy network that includes specialty pharmacy, retail pharmacy with compounding services, mail order pharmacy, and conveniently located retail pharmacies in and out of Santa Clara County.” Members must fill prescription drugs at a VHP Plan Pharmacy. Retail Pharmacy Members may receive up to a 90 day supply of prescription drug at retail pharmacies, restrictions may apply according to your Formulary. These network pharmacies include the following: • Countywide Valley Health Center pharmacies • Nationwide Walgreens pharmacies • Nationwide Safeway and affiliates pharmacies • Select local pharmacies • Some retail pharmacies may offer to mail your prescription drug. Please inquire at your local network pharmacy.

Mandatory Specialty Pharmacy (MSP) Certain Formulary drugs are classified as MSP drugs because they often treat complex, chronic conditions that involve more care management and may require specialized delivery and/or additional training for self-administration on an ongoing basis. Members may receive up to a 30 day supply for a MSP prescription drug. VHP has partnered with SCVMC Specialty Pharmacy and Diplomat Specialty Pharmacy to provide MSP drugs for our members. These specialty pharmacies have a dedicated team of pharmacists, specialty technicians, patient care coordinators and/or nurses available to answer all of your therapy and drug support needs. • Santa Clara Valley Medical Center (SCVMC) Specialty Pharmacy Services: 408.977.3542

Mail Order Pharmacy Prescription Drug Program Members have the choice to fill maintenance prescription drugs, between 60-90 day supply, for chronic conditions through the VHP mail service pharmacy administered by NoviXus. Members can enroll at www.Novixus.com or call 1.888.240.2211. Compounding Pharmacies Your Provider must continue to use the VHP Formulary when writing prescriptions, including those to be compounded. If an active ingredient in the compounded product is not on the VHP Formulary, your Provider is required to fill out a Non-Formulary Prescription Drug Prior Authorization Form. • Safeway Compounding Pharmacy: Compounds non-sterile and sterile compounds. • 844.448.2291 (toll-free), Monday-Friday 8-5 PST • Walgreens Pharmacy: Compounds only non-sterile compounds. Contact your local Walgreens to see if it has the compounding services you need.

Formulary Review & Updates The Valley Health Plan (VHP) drug formulary is reviewed quarterly and updated by the VHP Pharmacy and Therapeutics (P&T) Committee. The P&T Committee uses information from many sources to determine the status of each drug. The Committee decisions include adding drugs to the formulary, requiring prior authorization for some drugs, requiring quantity limits or step therapy, the process for generic substitution, therapeutic interchange, or not adding the drug to the formulary.

Navitus Health Solutions Navitus Health Solutions is VHP’s Pharmacy Benefit Manager. Navitus Health Solutions administers the pharmacy benefit on behalf of VHP including customer service, formulary maintenance, Prior Authorizations, Exception to Coverage, and drug recall notifications. Drug Recall Navitus receives notification from the USFDA recall posting. VHP members and prescribing practitioners affected by a Class II recall or voluntary drug withdrawals from the market for safety reasons will be identified and notified within 30 calendar days of the posting, and within two (2) business days for a Class I recall.

These decisions are based on US Food and Drug Administration (FDA) approval, scientific articles, drug safety, and whether there are other like drugs available that accomplish similar If you would like additional information on a results. recent recall, please visit www.navitus.com For information about VHP P&T Committee, please refer to your Valley Health Plan Benefits and Coverage Handbook – Combined Evidence of Coverage and Disclosure Form (EOC), including additional supplemental pharmaceutical management procedures. Occasionally, VHP will require your provider to fill out a Prescription Drug Prior Authorization Request Form for drugs that have Prior Authorization criteria or are not on the VHP Formulary. These forms will be reviewed by a pharmacist and/or a physician and approval will be based on established criteria and medical necessity. VHP posts a drug formulary and a summary of updates to the website quarterly after each VHP P&T meeting. Visit www.valleyhealthplan.org for additional information or to view the drug Formulary, summary of updates, and the EOC online.

• Diplomat Specialty Pharmacy: 877.977.9118

Visit www.valleyhealthplan.org to find a Plan Pharmacy near you. If you do not have access to the Internet and would like a printed copy of any material, please call VHP Member Services at 1.888.421.8444 (toll-free). 22 Perspectives | Summer - Fall 2017

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VHP CHIEF MEDICAL OFFICER Dolly C. Goel, MD VHP MEDICAL ADVISORS Stephen Harris, MD Michael Meade, MD Gary Steinke, MD

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San Jose, CA 95131

1.888.421.8444 (toll-free)