Advocare. Connection. Advocare Plan Expands. Preventive Guidelines. Controlling High Blood Pressure. Page 2. Page 5. Teri Mueller, R.N.

Transcription

1 Advocare Connection Advocare Plan Expands Page 2 Preventive Guidelines Page 5 Teri Mueller, R.N. Nonprofit Organization U.S. Postage Paid Security Health Plan of Wisconsin, INC. Security Health Plan of Wisconsin, Inc. PO Box 8000 Marshfield, WI Controlling High Blood Pressure Page 8

2 Shared decision making helps members choose appropriate care When you are in pain and surgery is one option for treatment, how do you know if it s the right choice? Sometimes a non-surgical treatment is the right choice. The challenge is that many times, patients don t have reliable information to help guide their decision about which treatment option is right for their situation. If you are covered by Security Health Plan, you now have a resource to guide your decision. In certain instances when surgery might be a treatment option, we will encourage you to complete a process that provides information about the surgery you are considering including the risks and benefits, as well as alternatives to surgery, and asks you questions about your lifestyle, personal values and care preferences. This is a process called shared decision-making and it will help you decide if surgery is right for you. You can then work with your physician to receive the appropriate care in the right setting. Studies show that when patients participate in shared decisionmaking, they are more satisfied with their care, which is one of the priorities we have for all of our members. This is one way that Security Health Plan is working to make sure you receive the right care at the right time in the right location, and in keeping with your personal values and situation. Advocare plans expanding in southern Wisconsin Security Health Plan is expanding the availability of its Advocare Medicare Advantage plans in Wisconsin and adding to its network of providers offering care to all Advocare plan members. Security Health Plan is offering its Advocare Medicare Advantage plans to residents of Waukesha, Iowa, Richland and Green counties with coverage starting in The annual enrollment period runs through December 7 for coverage that will begin January 1, Joining Security Health Plan s network of Advocare plan providers, which already included UW-Hospitals and Clinics, Meriter Health Systems, Sauk Prairie Memorial Hospital and Clinics, Reedsburg Area Medical Center and Marshfield Clinic, are these Southern Wisconsin health care providers: Group Health Cooperative of South Central Wisconsin ProHealth Care Monroe Clinic Upland Hills Health Richland Medical Center Security Health Plan has 42,000 Advocare members in Wisconsin. Please help us by telling your friends and family why you like Security Health Plan s Advocare Medicare Advantage coverage. A recommendation from you is our best advertisement. 2 Advocare Connection Fall 2013

3 High marks show Advocare plans are meeting your needs Every autumn Security Health Plan receives two critical report cards that measure how well we re serving you. It s gratifying to report that we scored high marks in both. I don t share these rankings to brag, but to emphasize that delivering the very best service to all of our members every day is the first priority of Security Health Plan and our network providers. For the ninth consecutive year Security Health Plan has been named one of America s best health insurance plans by the National Committee for Quality Assurance (NCQA) for its Medicaid, Medicare and Private plans. Steve Youso Chief Administrative Officer These rankings are determined through rigorous objective analysis, and can certainly help anyone choosing a quality health plan. Here s how we ranked by category in the NCQA Health Insurance Plan Rankings : Advocare Medicare Advantage plans rank 10th out of 405 plans ranked in the NCQA s Medicare Health Insurance Plan Rankings for Private (commercial) plans rank 45th out of 484 plans ranked in the NCQA Private Health Insurance Plan Rankings BadgerCare Plus Medicaid plans rank 12th out of 131 plans ranked in the NCQA s Medicaid Health Insurance Plan Rankings I m happy to add that we also received high marks from the Centers for Medicare and Medicaid Services for our Advocare Medicare Advantage plans for We received an overall rating of 4.5 in the 5-star rating that CMS uses to rank Medicare Advantage and Part D Prescription Drug plans. The ratings target clinical quality, consumer satisfaction, and other service standards. We scored a rating of 5 in the 5-star rating as a health plan, and 4.5 in the 5-star rating system for drug plan services. CMS adjusts its scoring system annually, which means insurance plans must adapt. We achieved this high rating by working with providers and members to manage members health. Taken as a whole, these report cards are an independent affirmation that Security Health Plan, in partnership with our providers, is making a healthy difference in the lives of our members and the communities we serve. As the head coach of the Security Health Plan team I m proud to see our extraordinary efforts achieve outcomes that will help you live a healthier life. Fall 2013 Advocare Connection 3

4 Care managers help you deal with major health issues Our care management programs can help you deal with overlapping health problems, repeated hospital admissions and chronic conditions. We can help you stay on track with your health care, assisting you in getting the right care, at the right place, at the right time. - Sherri Winer, R.N., assistant manager for Care Management Care and disease management programs Security Health Plan uses health assessments, information from providers, health care claims and requests of family members to identify our members who have specific health care needs as early as possible. Sherri Winer R.N., assistant manager for Care Management We encourage you to connect with one of our care managers, including registered nurses and social workers. Your care manager will help you better understand your situation and what you can do to improve your health. Our care managers can help you cope with many common diseases and health concerns. Not only do we care about your health, but we can help you lower your health care costs when your chronic conditions are in good control. Care managers will assist in coordinating care with your health care providers. There are two phone numbers to call for information about care management. To learn more or participate in any of these programs call Cancer Transplant support Transition to Home Other complex care management (after hospital stay) (other health concerns and questions) Behavioral health (mental health, substance abuse) To learn more or participate in any of these disease management or population health programs below call Expect Your Best Chronic obstructive pulmonary (healthy birth program) disease (COPD) High cholesterol Heart failure Diabetes High blood pressure (hypertension) Asthma Out of the Blue (depression program) Tobacco cessation Our members who have any of 17 less common conditions can receive the same personal care and support through our partnership with AccordantCare. If you have any other conditions or unusual needs with your health care, we are here to support you in getting the care you need, when and where you need it. Best of all, everything we do to help put you in control of your health care is offered to you at no additional charge as a benefit of having your health insurance through Security Health Plan. 4 Advocare Connection Fall 2013

5 Preventive care guidelines These recommendations are for adults at normal risk. Your health care provider may want you to start screening earlier or have screening more often if you are at higher risk. Service years years 65 and older Abdominal aortic aneurism screening Men ages who have ever smoked Blood pressure Blood pressure every two years if less than 120/80; every year if /80-89 and over Breast cancer screening Mammogram every one to two years for women ages 40 to 75 Cholesterol test Screening for men age 35 and women age 45 every five years. Age 50 and older (age 45 for African Americans, American Colorectal cancer screening Indians and Alaska natives). Colonoscopy is the recommended screening test. Other screening options are available. Influenza immunization (shot) Every year during flu season for all individuals Height, weight and body mass index At least once a year Osteoporosis screening Screening for women age 65 and older Physical exam Yearly exam for all ages Pneumococcal immunization Immunize if at high risk Immunize starting at age 65 if not done previously Vision screening Vision screening age 65 and older Zoster (shingles) vaccine Age 60 and over Know the standards for receiving care from your providers Security Health Plan members should receive timely access to medically necessary health care services. Here are some guidelines on how quickly Security Health Plan expects its members to be able to see primary care providers and behavioral health providers: Primary Care Providers Routine, non-urgent problems, focused primary care appointments (Examples include joint or muscle pain, blood pressure checks Urgent needs (Examples include persistent fever, sore throat, vomiting) Life-threatening emergencies (Examples include chest pain, severe bleeding, traumatic injury) Behavioral Health Providers Routine office visits (Examples include life stressors, mild depression) Urgent needs (An example would be medication reactions) Non life-threatening emergencies (Examples include psychosis, delirium) Life-threatening emergencies (Examples include potential for suicide, homicide) Follow-up after hospitalization for mental health illness Members should be able to get care within: 14 calendar days 24 hours Immediate access Members should be able to get care within: 10 business days 48 hours 6 hours Immediate access Within 7 calendar days Fall 2013 Advocare Connection 5

6 Advance directives: Let your wishes be known You have the right to accept or refuse treatment and to complete an advance directive. Completing an advance directive can lessen the burden on your loved ones and make sure your wishes are honored, said Judy LeMaster, Nurse Manager at Security Health Plan. When you create an advance directive you take control of health care decisions for yourself in the event you are unable to make such decisions in the future. In Wisconsin if you are 18 years of age or older and of sound mind you can complete an advance directive. Three kinds of health care advance directives are available: 1 Power of attorney for health care (used for health decisions) 2 Living will (declaration to doctors) Do not resuscitate order and bracelet (used for terminal illness) 3 This is really about planning, said LeMaster. You can say, Here are my wishes. This is what I want. Discuss your wishes with those who will be around you, including your loved ones, health care agents and primary care provider. When traveling, carry a card that would alert emergency responders that you have completed an advance directive, LeMaster said. When you complete your advance directive you can help your physicians, but more importantly, you help your family and you help yourself, she added. Call Security Health Plan s Advocare Customer Service Department at (TTY ) and we can mail this information to you. We are open from 8 a.m. to 8 p.m. seven days a week, if you have questions or concerns about advance directives. We will mail you an advance directives packet at no charge. Complaint procedures Federal law requires that Advocare plan members admitted to health care facilities be provided information about advance directives. Members dissatisfied with a facility s advance directives policy and process have the right to file a complaint with these agencies: Hospitals Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Skilled nursing facilities and home health agencies State of Wisconsin Division of Quality Assurance- bqaconsumer/healthcarecomplaints.htm For help to make a complaint, call (TTY ) and ask for an Advocare plan care manager. A care manager will help you identify the correct agency to which to log your complaint. Get the latest updates to your coverage Medicare has issued National Coverage Determinations (NCDs) for the following medical services to be covered by your Advocare plan under certain conditions. Positron emission tomography (FDG) for solid tumors Cardiac pacemakers: Single-chamber and dual-chamber permanent cardiac pacemakers Bariatric surgery for the treatment of morbid obesity - facility certification requirement Beta amyloid positron emission tomography in dementia and neurodegenerative disease Ventricular assist devices for bridge-to-transplant and destination therapy For details about NCDs visit If you do not have Internet access call our Customer Service Department at (TTY ) and we can mail this information to you. We are open from 8 a.m. to 8 p.m. seven days a week. 6 Advocare Connection Fall 2013

7 Thank you for helping us serve you better The reply card in the last Advocare Connection asked for your thoughts on what we might explain better. Here are some of your responses: Advocare Connection What if I want more information about health insurance topics? R: Our newly updated website is a great source of information about health insurance. Check it out at Evidence of Coverage - What services does my plan cover? Learn the Basics - How does health insurance work? Provider Directory - What providers can I use? Notice of Privacy Practices - How is my privacy protected? Fraud, Waste and Abuse information - What do I do if I suspect I m a victim of fraud? Personal Health Statement Log in to Security Health Online to see my health care usage and make sure my claims are correct. I couldn t find a provider who I know is in my community. R: If you are searching our printed Advocare plan Provider Directory in a community that crosses a county line, please look in both counties to make sure you find all the available options. If you don t find a provider you believe should be there, please use the Find a Doctor search on our website, Click on Advanced Search and search by the city name. If you need assistance, please call Customer Service at (TTY ). Always improving quality Security Health Plan wants to ensure you get high-quality health care. We work with your doctors to improve programs and services for you. To find out more about our quality improvement efforts, visit and click on About Us, then select Quality Assurance. To request a paper copy, call (TTY: ). Advocare Connection is published for members of Security Health Plan. Information comes from a wide range of medical experts. Models may be used in photos and illustrations. If you have any concerns or questions about specific content that may affect your health, please contact your health care provider. How to reach us: Customer Service: (TTY: ) 8 a.m. to 8 p.m., 7 days a week Website: New address? Let us know by calling our Customer Service Department. Copyright 2013 Security Health Plan of Wisconsin, Inc. Fall 2013 Advocare Connection 7

8 We can help you control high blood pressure High blood pressure can quietly damage your body for years before any symptoms appear. Unchecked it can contribute to heart disease, stroke and other life-threatening complications including kidney failure and brain damage. We encourage our members to take steps that can help control, even lower, high blood pressure, said Teri Mueller, R.N., one of Security Health Plan s nurse care managers. And we have a program that can help them. According to the Centers for Disease Control, nearly 70 million Americans have hypertension, more commonly known as high blood pressure. It can affect people of all ages, but is more common as we age. Teri Mueller R.N., nurse care manager Blood pressure is the force of blood pushing through arteries. A normal measurement is 120 systolic (pumping) over 80 diastolic (at rest). When the measurement reaches 140 over 90, it is considered high blood pressure. There are a number of factors that can lead to high blood pressure - heredity, diet, stress, weight and diabetes, Mueller said. If you have high blood pressure there are some measures that you can take. Your first step should be a visit with your doctor to determine what treatment options might help, Mueller said. For some people increased exercise and a healthier diet can help. Others take prescription medications that help lower blood pressure, Mueller said. Some members have a monitoring device that regularly sends blood pressure information directly to their doctor s office. It s so important to stress that high blood pressure isn t something to ignore. For more information about programs for coping with high blood pressure call a Security Health Plan care manager at