The newsletter for NHP members Our Neighborhood MEDICAID AND COMMERCIAL Spring Summer 2012 Vaccines for kids & teens Asthma control & triggers Type 2 diabetes & exercise Obstructive sleep apnea 3 5 6 7 nhp.org
Where you see this symbol, more information is available on the web. From the NHP homepage (www.nhp.org), click on Healthwise Knowledgebase under Quick Links on the left side of the page. Health insurance fraud What it is and how can you prevent it? When a person gets health care by using a health card that is not theirs, that is called health insurance fraud. It is also fraud when a person tries to be paid for a service they did not provide. How to prevent insurance fraud: Do not give your NHP or MassHealth member number to anyone except your doctor, clinic, hospital, or other healthcare provider. Do not ask your doctor or other healthcare provider for medical care that you do not need. If someone offers you free tests or screenings in exchange for your health insurance number you should question it. Look at any healthcare bill or statement you receive carefully. NHP should be billed only for services that you have received. Do not believe anyone who tells you that they know how to get healthcare services paid for, even those not usually covered. Do not let anyone borrow your health insurance card and do not use anyone else s card. If you think someone may be guilty of fraud, please report it to NHP s Anonymous Phone Line: 1-800-826-6762. Your call is private and you do not need to give your name. All NHP members with MassHealth coverage must reapply every year Your family s health insurance is important. Do not lose it! Fill out the Eligibility review forms. If you are a MassHealth member, MassHealth will send you a set of forms to fill out at least once a year. Make sure you open all mail from MassHealth so you can fill out the forms and send them in on time. If you need help filling out your review form, ask at your health center. Remember, if you do not complete the form and send MassHealth any of the information they ask you for, you may lose your MassHealth coverage. Join NHP s new commercial member Advisory Committee! NHP is looking for members for a new Commercial Member Advisory Committee. This committee would be for NHP members who have an NHP Choice Plan or an NHP Care Plan. If you are an NHP member who has purchased your insurance through one of the following, we want to hear from you: Your employer A broker The Connector s Commonwealth Choice program Members who join will get a VISA gift card for each meeting that they attend. If you would like to be a member that helps NHP improve its services, or would just like to know more, call 617-979-5815 to speak to NHP s Member Advisory Committee staff member, or call the NHP Member Service Center at 1-800-462-5449. Mobile Crisis Intervention Service What is Mobile Crisis Intervention? Mobile Crisis Intervention (MCI) is a short-term crisis intervention service for youth under the age of 21. This service is for youth experiencing a mental health or substance use crisis. The goal is to assist the youth and family in resolving the crisis and being able to continue to care for the youth at home, thereby preventing an out-of-home placement. MCI can work with the youth and their family to assess, treat, and stabilize the emergency situation and reduce the immediate risk of danger to the youth or others. MCI can be used as an alternative to calling 911 or going to a hospital emergency room in situations that are not life threatening or do not require emergency medical intervention. MCI can provide referrals and linkages to other mental health and/or substance use services and supports. MCI is an active treatment service and the parent/guardian must be present during treatment interventions, particularly when they are provided in the youth s home. MCI is not a respite or staffing service. Where is Mobile Crisis Intervention provided? MCI is primarily a mobile service that can travel to wherever the youth is experiencing the crisis such as in the youth s home, school, residential program, or on-site at the MCI provider s location in your community. There is an MCI program that covers every city and town in Massachusetts. When is Mobile Crisis Intervention Available? MCI is provided 24 hours a day, 7 days a week, 365 days a year. What is new about Mobile Crisis Intervention? Previously, the MCI service was available for up to 72 hours as needed to help stabilize the crisis and assist the youth in remaining in their home. As of May 31, 2012, MCI will be available for up to 7 days as medically necessary to achieve these goals. The amount of time the MCI provider will actively work with the family during a period of up to 7 days will depend on the needs of each youth. How you can locate the MCI provider near you? Go to www.masspartnership.com/esp, or call the Statewide ESP/MCI Toll Free Number: 1-877-382-1609 and enter your zip code.
Stick to the CDC's vaccination schedule for your children The Centers for Disease Control and Prevention (CDC), lists 14 vaccines that will protect children from major diseases during their lifetime. Children should get the vaccines (shots) before the age of six. It is very dangerous when children do not get the shots at the right time. New reports say that nearly 10% of parents in America do not stick to the CDC s schedule for shots. Children who are not vaccinated are not protected. They have a greater risk of catching diseases. And, a sick child can pass it to others who may not be able to fight it. The disease could spread to schools and communities. When children do not get their shots, they are at risk and they put others at risk. General immunization questions can be answered by the CDC Contact Center at 1-800-CDC-INFO (1-800-232-4636) English and Español (TTY 1-888-232-6348). Source: Parents should stick to CDC s vaccination schedule for children By Dr. Steven Kairys, October 29, 2011, Times of Trenton guest opinion column Vaccines schedule for teens Babies are not the only ones who need vaccines. Pre-teens and teenagers need vaccines to stay healthy. Vaccines for kids and teens Pregnant women need a Tdap booster shot (after 20 weeks of pregnancy) In recent years, there have been outbreaks of whooping cough (pertussis) across the country. Several newborns have caught it and died. Babies can t get the first dose of the vaccine until they are two months old. By getting this shot, a woman can help protect her baby from getting the disease. Family members and anyone who will be caring for a newborn should also get the vaccine. Pre-teens need these shots by age 11: If you are pregnant, talk to your PCP about the The Tdap vaccine (booster shot) protects against tetanus, Tdap vaccine. diphtheria, and pertussis or whooping cough. These diseases can cause serious health problems. While infants and toddlers are vaccinated against these diseases, the protection begins to wear off as kids get older. The Meningococcal Conjugate vaccine (MCV4) protects against meningococcal disease. This very serious disease is the top cause of bacterial meningitis in children. About 1 of every 10 people who get the disease will die from it. Those who survive the disease may have health problems for the rest of their life. College-bound teens should get the vaccine before they go. The disease is spread by sneezing, coughing, and kissing. The HPV vaccine protects girls and women from strains of the human papillomavirus that can cause cervical cancer. It protects boys from strains of the virus that cause anal cancer and genital warts. It is very important to receive the full series of shots for full protection. Teens should get a flu shot each year to protect them from the flu. Most people who get the flu will get better. However, teens can get very sick and miss school and other activities. Getting the flu shot helps to prevent the spread of the flu to others who may not be able to fight it as well. NHP Member Service Center 1-800-462-5449 3
Know the signs of drug and alcohol abuse Alcohol and drug use in the United States is common. Alcohol is the most common drug abused by children between 12 and 17 years old. About 4 out of 10 Americans will use an illegal drug at some point in their lives. Drug abuse includes the use of drugs, such as marijuana, cocaine, heroin, LSD, ecstasy, and other street drugs. Drug abuse can also mean not using medicines the way they should be used. People who have a problem with alcohol or drugs cannot stop drinking or using drugs even when it has a bad effect on their life. Why someone drinks or takes drugs is another sign of a problem. Sometimes people drink or use drugs to cope with stress or their feelings. How do you know if someone has a problem with alcohol? A person may have an alcohol problem if his or her drinking: Causes health problems Causes problems with day-to-day activities (like work or school) Causes problems with family and friends Starts in the morning or at other unusual times of the day More signs of a possible drug or alcohol problem: Personality changes Denial of the problem Poor eating or sleeping habits No interest in favorite activities Red eyes, sore throat, or dry cough Body shakes How to Get Help Talk with your primary care provider (PCP). Your PCP may give you the name of someone you can call who has special training in this area. You can also call Beacon Health Strategies, NHP s behavioral health partner, to help you find a doctor or counselor. Go to the website, www.nhp.org. Click on Members and then click on Locate a Provider Call Beacon s 24-hour Clinical Access Line at 1-800-414-2820 Visit Beacon s website at www.beaconhealthstrategies.com for general information about alcohol and drug problems. Click on Member Materials, then Alcohol and other drugs. New study shows Americans are eating too much salt The typical American diet has too much sodium (salt). Too much sodium is bad for your health. It can raise your blood pressure and your risk for a heart attack and stroke. Heart disease and stroke are the first and third killers of men and women in the United States each year. For most people, blood pressure begins to lower within a few days to a week when they cut back on sodium. Lowering sodium intake could prevent thousands of deaths a year. How much is too much sodium? We all need a small amount of sodium so our bodies will work right. The dietary guideline for adult sodium intake is no more than 2,300 mg of sodium per day. However, the average amount of sodium for most Americans is 3,436 mg per day! You should eat no more than 1,500 mg of sodium per day, if: You are 51 years of age or older You are African American You have high blood pressure You have diabetes You have chronic kidney disease Where is all this sodium coming from? Most of the sodium we eat comes from packaged, processed, store-bought, and restaurant foods. Only a small amount comes from table salt and salt added during cooking. You can find out how much sodium is in food by checking the labels on food products. When you eat out, ask for information about the sodium content. Most sodium comes from processed foods and restaurant meals Processed and restaurant foods Naturally-occurring Table salt Home cooking 24 NHP Member Newsletter Fall Spring Winter Summer 2011 2012
The number of people with asthma has doubled in the past 20 years. Every year there are more than 2 million emergency room visits, 500,000 hospitalizations, and nearly 3,800 deaths related to asthma. Uncontrolled asthma and asthma deaths happen when asthma is not treated or managed incorrectly. Take Control of Asthma There are many factors related to asthma control. If you understand what it means to have your asthma in control, you can manage it better. The goal should be to feel good, be active all day and sleep well at night. You can reduce the effects of the disease on your life. You can control your asthma! If your asthma is in control, you should: Have no asthma symptoms (or very few) Be able to do all your activities and exercise Not miss school or work Rarely have asthma attacks Not have to go to the emergency room or stay in the hospital Have less need for quick-relief medications Asthma Control and Medicine You can control your asthma and avoid an attack. Take your medicine the way that your health care provider tells you to do and avoid things that can cause an attack (triggers). Quick-relief medicines control the symptoms of an asthma attack. If you Asthma: Control & Triggers need to use your quick-relief medicines more and more, you should talk with your health care provider. You may need a different medicine. Long-term control medicines help you have fewer and milder attacks. But they will not help you if you take them when you are having an asthma attack. Avoid Asthma Triggers Often, the best way to control asthma is to stay away from what triggers them the symptoms. Know your triggers and avoid them. Triggers vary from person to person. Some common asthma triggers are: Dust mites Keep mattresses and pillows in dust proof covers. Pets Don t have pets with fur or feathers. Indoor Mold Clean moldy surfaces. Keep shower curtains clean. Pollen Stay inside when pollen levels are high. Colds Avoid people with colds. Wash your hands frequently. Exercise Ask your doctor if you need medicine before you exercise. Smoking Don t smoke. Stay away from smoky areas. Sources: Center of Disease Control and Prevention. (2005) National Center for Health Statistics: Summary of Health Statistics for Adults and Summary of Health Statics for Children. Accessed from ww.cdc.gov/nchs/fasats/asthma.htm The National Heart and Lung and Blood Institute's National Asthma Education and Prevention Program entitles: The Expert Panel Report 3: Guidelines for Diagnosis and Management of Asthma, 2007 Do you have a primary care provider? All Neighborhood Health Plan members must choose a Primary Care Provider (PCP). Your PCP can be a: Doctor Nurse Practitioner Physician Assistant It is a good idea to meet your PCP before you become sick. Your PCP needs to get to know about you and your health habits and needs to know you from head to toe. You need to know if it is easy to talk to your PCP. Your PCP will: Give you regular exams See you when you are sick Tell you when to see a specialist Help you manage chronic illnesses (like high blood pressure or high cholesterol) A chronic illness is a sickness that never goes away, such as high blood pressure. Even if you are not sick, you need a PCP. If you need help getting a PCP: Use the NHP provider directory to find a PCP Call the NHP Member Service Center at 1-800-462-5449. The Member Service Center is open Monday through Friday from 8:00 a.m. to 6:00 p.m. and Thursday until 8:00 p.m. NHP Member Customer Service Care Center 1-800-462-5449 53
My aching back! The truth about low back pain At some time in their life, most adults will have low back pain due to a minor back problem. Most injuries happen during sports, work tasks, or home projects. The good news is that most back pain goes away within 1 4 weeks with some first aid and self-care. Low back pain from strained muscles may take longer (4 6 weeks). MRI s, x-rays and surgery are not helpful in these cases. While your back is healing, it is best to keep up with your normal routine. However, try not to make it worse and no heavy lifting! Neighborhood Health Plan members can learn how to care for back pain and other health problems. Here s what to do: Get a copy of the Healthwise Handbook in the mail. Call the Member Service Center (MSC) at 1-800-462-5449 (TTY: 1-800-655-1761). Call the MSC to find out if we have a care management program that is right for you. Visit NHP s website (www.nhp.org) and check out the Healthwise Knowledgebase tools. Click on For Members or Your Health. Healthwise Knowledgebase is on the left side of the page. To learn about Back Pain, click on the letter B under Topics A-Z. Find out what might be causing your pain. Answer questions and get advice from The Symptom Checker. Use the Health Decision Tools to learn about medical tests, medicines, any surgeries. If you need medical advice right away, call Neighborhood Health Plan s Nurse Advice Line at 1-800-462-5449. You can also call your doctor s office. Even when they are closed, your primary care practice has a doctor or nurse on call. Note: Although it is not the usual case, some back pain may be a sign of a more serious condition. You should call your doctor s office if you have back pain along with any of these symptoms: A fever Loss of bladder or bowel control Back pain that gets worse at night Exercise! No excuses for type 2 diabetes. If you have type 2 diabetes; you may have heard this advice before: Take your medicines the way your doctor tells you to Check your blood sugar and have regular health screenings Eat healthy foods. Watch your carbs and limit salt (sodium) Stay active exercise! You may be very clear about the first three items. You know what to do; but you may not know as much about exercise. Exercise plays a key role in the care of diabetes. Regular exercise (aerobic and strength training) has a positive effect on: Blood sugar control Blood pressure Heart health Quality of life The American Diabetes Association has exercise guidelines. They take into account that some people may have health problems related to diabetes. This should not be an excuse not to exercise. Almost all people with type 2 diabetes can exercise as long as they do it safely. Talk to your primary care provider about the best exercise program for you. The guidelines for people with type 2 diabetes are: Aerobic Exercise Strength Training 2.5 hours every week 3 days per week Every other day Not more than 2 days off 2-3 times a week Every other day A few tips to keep you safe and help you stick with your program: Work with a qualified person if you are new to strength training Aerobic exercise should be moderate or higher effort* Use a pedometer to count your steps Set goals (such as taking 10,000 steps per day) * Brisk walking is an example of moderate effort Sources: New Guidelines for Exercise in Type 2 Diabetes, www.medscape.com 4 NHP Member Newsletter Fall Winter 2011 6 NHP Member Newsletter Spring Summer 2012
What is it? Obstructive sleep apnea is caused by blocked or narrowed airways in your nose, mouth, or throat. During sleep, the throat muscles and tongue relax. For most people it is not a problem. It is not normal if it causes you to have trouble breathing. Sleep apnea may cause problems during the night that interfere with sleep. If you have sleep apnea, you may not be sleeping as well as you could. You may be more likely to end up with serious problems such as high blood pressure, heart problems, stroke, depression, or diabetes. What are the symptoms? People who have sleep apnea may wake up feeling very tired in the morning. Other symptoms of sleep apnea are: Trouble staying awake during the day Not being able to focus Problems with memory Morning or night headaches The latest guidelines and expert advice on home sleep studies What causes it? Sleep apnea is more likely to occur if you are overweight. Sleeping on your back, drinking alcohol before bed, or taking certain medicines may also be a cause. Sometimes the cause is out of your control. You may have bones that are not a normal shape or you have tissues in your nose, mouth, or throat that are too big. In children, the main cause of sleep apnea is large tonsils or adenoids. Up until a few years ago, the use of home testing kits for the diagnosis of obstructive sleep apnea was not common. Now the American Academy of Sleep Medicine approves of the use of portable monitors under certain conditions. Home testing requires a prescription from a sleep specialist who has ruled out the need for a full overnight sleep study. Home testing may be an option for people: Between 18 and 65 years of age With no other major medical problems With no other sleep disorders Who cannot have a study in a sleep lab Home testing may also be used after the diagnosis has been made to monitor some treatments. Obstructive Sleep Apnea Do you have trouble sleeping, wake up tired or snore loudly? You may have Obstructive Sleep Apnea. What can you do? Talk to your primary care provider (PCP) if you think that you may have this condition. If you have mild sleep apnea, your PCP will talk to you about lifestyle changes that you can make that should help you sleep better. If you are at high risk for sleep apnea, you may need to use an oral breathing device at night. In some cases, surgery may be needed. Your PCP may refer you to a sleep specialist for a sleep study. What is a sleep study? The best way to confirm sleep apnea is with an overnight sleep study. Sleep studies can provide important information that will help the specialist decide the best treatment for you. Usually these studies are done in a hospital or sleep lab but in some cases, they can be done at home. NHP Member Service Center 1-800-462-5449 7
Neighborhood Health Plan 253 Summer Street, Boston, MA 02210 www.nhp.org Smoking and pregnancy Janet Koslow, NHP s Tobbacco Treatment Specialist If you are pregnant and you smoke, you need to know the facts. One of the most important things to do for your health and your baby s is to quit now. Smoking during pregnancy can hurt your baby. Tobacco smoke is toxic. When you smoke during pregnancy: Toxins are passed to your baby The flow of blood from you to the baby is reduced The risk of sudden infant death syndrome is greater Your baby could have a low birth weight or develop asthma When your baby is born, if you still smoke: Your baby may have more colds, coughs, and ear infections Your baby may have lung problems It is hard to quit smoking. It is even harder if you are pregnant because you cannot use medicine. Still many women make the right choice and quit. If you want to quit, you can get help. Talk to your primary care provider about the help you can get in your area. You can also join NHP s Quit Smoking Program. To speak with a care manager about the program call 1-800-433-5556, extension 1447 (or send an email to quitsmoking@nhp.org). Our Neighborhood A publication of Neighborhood Health Plan Boston, Massachusetts NHP Customer Service Center 1-800-462-5449 Deborah Enos, President and CEO David Segal, Chief Operating Officer Paul Mendis, MD, Chief Medical Officer James Glauber, MD, Senior Medical Director Matthew Collins, MD, Medical Director Jim Hellinger, MD, Medical Director Laura Noble, BS, MPA/Health Policy Health Education and Wellness Advisor Rhian Gregory, Director, Marketing and Corporate Communications Nicole Fletcher, Marketing and Corporate Communications Manager Laurie Hill Dunning, Senior Marketing and Corporate Communications Specialist The content of this newsletter is general information provided for educational or reference purposes only and is not a substitute for professional medical advice. All photographs are for illustrative purposes only. Models in photographs have no real life connection to the subject matter of the articles. Neighborhood Health Plan is a trademark of Neighborhood Health Plan, Inc. All other names are used for identification purposes only and are trademarks or registered trademarks of their respective companies. 2011 Neighborhood Health Plan, Inc. All Rghts Reserved 10063-0312-07
Important information for Neighborhood Health Plan members Member rights and responsibilities As a valued member of Neighborhood Health Plan (NHP), you have the right to: Receive information about NHP, our services, our providers and practitioners, your covered benefits, and your rights and responsibilities as a member of NHP. Receive oral interpretation services free of charge for any materials in any language. Have your questions and concerns answered completely and courteously. Be treated with respect and with consideration for your dignity. Have privacy during treatment and expect confidentiality of all records and communications. Discuss and receive information regarding your treatment options, regardless of cost or benefit coverage, with your provider in a way which is understood by you. You may be responsible for payment of services not included in the covered services list for your coverage type. Be included in all decisions about your health care, including the right to refuse treatment. Change your primary care provider. Access emergency care twenty-four (24) hours a day, seven (7) days a week. Access an easy process to voice your concerns, and expect follow-up by NHP. File an appeal or complaint if you have had an unsatisfactory experience with NHP or with any of our contracted providers, or if you disagree with certain decisions made by NHP. Make recommendations regarding NHP s member rights and responsibilities. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Freely apply your rights without negatively affecting the way NHP and/or your provider treats you. Ask for and receive a copy of your medical record and request that it be changed or corrected. Receive the covered health services you are eligible for as outlined in your member handbook or covered services list. As a member of NHP, you also have responsibilities. It is your responsibility to: Choose a primary care provider, the provider responsible for your care. Call your primary care provider when you need health care. Tell any health care provider that you are an NHP member. Give complete and accurate health information that NHP or your provider needs in order to provide care. Understand the role of your primary care provider in providing your care and arranging other medical services that you may need. To the degree possible, understand your health problems and take part in making decisions about your health care and in developing treatment goals with your provider. Follow the plans and instructions agreed to by you and your provider. Understand your benefits what s covered and what s not covered. Call your primary care provider within forty-eight (48) hours of any emergency or out-of-area treatment. If you experienced a behavioral health (mental health and substance abuse) emergency you should contact your behavioral health provider, if you have one. Notify NHP and MassHealth of any changes in personal information such as address, phone, marriage, additions to the family, eligibility of other health insurance coverage, etc. Understand that you may be responsible for payment of services you receive that are not described as covered in your member handbook or covered services list for your coverage type. Benefit coverage and obtaining care Neighborhood Health Plan (NHP) is a licensed health maintenance organization (HMO). As an HMO, we have certain requirements that you, as a member, must meet in order to ensure coverage of health care services that you receive. NHP also has certain obligations to you that we must fulfill as part of our agreement with you. These requirements and obligations are found in your NHP member handbook. If you are a commercial member, please also refer to your Benefit Summary. If you are a MassHealth member, please refer to your NHP covered services booklet and excluded services list. All of these documents can be found on NHP s website at www.nhp.org. Your NHP member handbook and your benefits or services documents are important and contain the following: NHP s toll-free number and hours of operation The name and customer services telephone number of any of NHP s subcontractors The availability of interpretation services by telephone for non-english members The availability of written materials in different languages or alternative formats and how to obtain them Benefits and services included in, and excluded from, coverage and how to access those benefits and services Pharmacy benefits, procedures, and programs Behavioral health benefits Copayments and other charges for which you are responsible Benefit restrictions and non-covered services, your access to them, and the cost How to submit a claim for covered services How to obtain information about providers who are in NHP s network How to obtain primary care services, the role of primary care providers, and where to access them How to obtain specialty care services and hospital services and the referral process How to obtain behavioral health services How to obtain services after normal office hours How, when, and where to obtain emergency services How to obtain care and coverage when you are out of the service area How to obtain information on advance directives or end of life planning How to voice a complaint or grievance How and when to appeal an NHP decision and the effects on your covered services How to obtain a hearing on an NHP decision at the Board of Hearings or the Office of Patient Protection How NHP evaluates new technology What your rights and responsibilities are as an NHP member As an NHP member, you are required, with certain exceptions, to obtain services from NHP-contracted providers in the NHP network. You can choose a provider by going to NHP s Provider Directory on our website at www.nhp.org, or you may request a printed copy by calling NHP at 1-800-433-5556. Privacy practices NHP believes it is important to protect your personal health information. This section describes how health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. NHP provides health insurance coverage to you. Because you get health benefits from NHP, we have personal health information (PHI) about you. By law, NHP must protect the privacy of your health information.
This section explains: When NHP may use and share your health information. What your rights are regarding your health information. NHP may use or share your health information: When the U.S. Department of Health and Human Services needs it to make sure your privacy is protected. When required by law or a law enforcement agency. For payment activities, such as checking if you are eligible for health benefits, and paying your healthcare providers for services you get. To operate programs, such as evaluating the quality of healthcare services you get, and performing studies to reduce healthcare costs. With your healthcare providers to coordinate your treatment and the services you get. With health-oversight agencies, such as the Federal Centers for Medicare and Medicaid Services, and for oversight activities authorized by law, including fraud and abuse investigations. For research projects that meet privacy requirements, and help us evaluate or improve NHP programs. With government agencies that give you benefits or services. With plan sponsors of employer group health plans, but only if they agree to protect that information. To prevent or respond to an immediate and serious health or safety emergency. To remind you of appointments, benefits, treatment options, or other health-related choices you have. When State privacy law is stricter than Federal privacy law, NHP will follow the stricter law. For example, Massachusetts state law requires NHP to get your written permission before sharing sensitive information such as HIV/AIDS or drug abuse. Except as described above, NHP cannot use or share your health information with anyone without your written permission. You may cancel your permission at any time, as long as you tell us in writing. Please note: we cannot take back any health information we used or shared when we had your permission. You have the right to: See and get a copy of your health information. You must ask for this in writing. NHP may charge you to cover certain costs, such as copying and postage. Ask NHP to change your health information if you think it is wrong or incomplete. You must tell us in writing which health information you want us to change, and why. Ask NHP to limit its use or sharing of your health information. You must ask for this in writing. NHP may not be able to grant this request. Ask NHP to get in touch with you in some other way, if by contacting you at the address or telephone number we have on file, you believe you would be harmed. Get a list of when and with whom NHP has shared your health information. You must ask for this in writing. Get a paper copy of this notice at any time. These rights may not apply in certain situations. By law, NHP must give you notice explaining that we protect your health information, and that we must follow the terms of this notice. NHP can change how we use and share your health information. If NHP does make important changes, we will send you a new notice. That new notice will apply to all of the health information that NHP has about you. NHP takes your privacy very seriously. If you would like to exercise any of the rights we describe in this notice, or if you feel that NHP has violated your privacy rights, contact NHP s Privacy Officer in writing at the following address: Neighborhood Health Plan Privacy Officer 253 Summer Street Boston, MA 02210-1120 Filing a Complaint or exercising your rights will not affect your benefits. You may also file a Complaint with the U.S. Secretary of Health and Human Services at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Washington, DC 20201 Telephone: 202-619-0257 Toll Free: 877-696-6775 For more information, or if you need help understanding this notice, call NHP s Customer Service Center at 1-800-462-5449 (TTY 1-800-655-1761), Monday through Friday, 8:00 a.m. to 6:00 p.m., Thursdays until 8:00 p.m. Confidentiality NHP takes our obligation to protect your personal and health information seriously. To maintain your privacy, we have instituted the following practices: NHP employees do not discuss your personal information in public areas such as the cafeteria, on elevators or when out side of the office. Electronic information is kept secure through the use of passwords, automatic screen savers, and limiting access to only those employees with a need to know. Written information is kept secure by storing it in locked file cabinets, enforcing clean-desk practices, and using secured shredding bins for its destruction. All employees, as part of their initial orientation, receive training on our confidentiality and privacy practices. All providers and other entities with whom we need to share private information are required to sign agreements in which they agree to keep that information confidential. NHP only collects information about you that we need to have in order to provide you with the services you have agreed to receive by enrolling in NHP or as otherwise required by law. In accordance with state law, NHP takes special precautions to protect any information concerning mental health or substance abuse, HIV status, sexually transmitted diseases, pregnancy, or termination of pregnancy. Summary of NHP s 2011 Quality Improvement Program Evaluation Each year, Neighborhood Health Plan writes a Quality Work Plan. The plan has goals and lists the steps we need to take to improve: Clinical quality Service quality Patient safety The 2011 Quality Work Plan targeted over 26 areas. Some of those are: Asthma care Diabetes care Well child care Wellness and prevention Member satisfaction Telephone service Access to appointments At the end of each year, NHP checks each goal. The results help form the plan for the next year. We find that NHP performs very well in well child care. NHP more than met the goal for the number of children getting checkups in all age groups. We also had more than the goal for the number of pregnant women getting prenatal care. Not as many women go to their postpartum visit. Many new projects started in 2012 will try to grow the number of women going to that important first visit after their baby is born. A look back at the 2011 plan shows that not all members understand their benefits and coverage. We will focus on that in 2012. To help members know more about their deductibles and cost-sharing requirements, we are printing handouts.
We are also going to make the member information on the website more helpful and easier to use. NHP is proud of the many goals met in 2011. As we are always working to improve, we have higher goals in the Quality Management Work Plan for 2012. Post-mastectomy benefits NHP, as required by the Women s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. For more information, call the NHP Customer Service Center at 1-800-462-5449 (TTY 1-800-655-1761) for more information. Appeal and grievance process As a Member of NHP, your satisfaction is important to us. If you feel you had an unsatisfactory experience with NHP, Beacon, or with any of our contracted Providers, you have the right to file a Grievance (complaint), which is a way to show that you are not satisfied with your experience. If you are not satisfied with a decision regarding health care coverage made by Neighborhood Health Plan (NHP), or you have had a problem accessing health care services, you, or your Authorized Representative, have the right to Appeal. To file a Grievance or an Appeal, you can write to NHP, provide information in person, or call our Customer Service Center 1-800-462-5449 (TTY: 1-800-655-1761). Neighborhood Health Plan Member Appeal/Grievance Coordinator 253 Summer Street Boston, MA 02210 If your Grievance or Appeal is related to Behavioral Health, call Beacon at 1-800- 414-2820, or write to: Beacon Health Strategies 500 Unicorn Park Drive Woburn, MA 01801 Preventive care guidelines for children Children who are under age 21 should go to their primary care provider for checkups even when they are well. As part of a well-child checkup, your child s doctor will offer screenings that are needed to find out if there are any health problems. These screenings include: Health Vision Dental Hearing Behavioral health Developmental Immunization status NHP pays for your child s checkups. At wellchild checkups, your child s Primary Care Provider can find and treat small problems before they become big ones. The ages to take a child for full physical exams and screenings are: 1 to 2 weeks 1 month 2 months 4 months 6 months 9 months 12 months 15 months 18 months Ages 2 through 20 children should visit their doctor once a year. Children should also visit their doctor any time there is a concern about their medical, emotional, or behavioral health needs, even if it is not time for a regular checkup. Preventive care guidelines for adults Routine preventive care is an important part of staying healthy. NHP urges all members to visit their primary care providers for preventive care. Examples of covered preventive care benefits include: Physical exams every one to three years Blood pressure monitoring at least every two years Cholesterol screening every five years Pelvic exams and Pap tests (women) initiate Pap test and pelvic exam at three years, after first sexual intercourse, or by age 21. Every one to three years, depending on risk factors. Breast cancer screening/mammogram every year over age 40 Colorectal cancer screening fecal occult blood test annually, sigmoidoscopy every 3 to 5 years, colonoscopy every 10 years starting at age 50 Flu shot annually Eye exams once every two years Diabetes screen every three years beginning at age 45. Screen more often and beginning at a younger age for those who are overweight and if risk factors are present. Dental call the NHP Customer Care Center to ask about specific dental coverage that is available through NHP or MassHealth. NHP covers many more preventive care benefits. Talk to your primary care provider for your routine health care needs. Changes to pharmacy benefits NHP reviews and updates coverage for FDA approved medications throughout the year. The NHP website is updated monthly as these changes occur. For the most accurate information, go to: www.nhp.org and click on Drug Lookup. Incentives statement NHP recognizes that under-use of medically necessary services has the potential to have an adverse affect on our members health and wellness. For this reason, NHP promotes appropriate use of services. NHP s utilization management (UM) decisions are based only on appropriateness of care and service and existence of coverage. NHP does not specifically reward practitioners, or other individuals, conducting utilization reviews for issuing denials of coverage or service, nor does NHP provide financial incentives to UM decision-makers to encourage decisions that result in under-use of medically necessary services. Utilization management For information about the utilization management (UM) process, and authorization requests and decisions, you have access to NHP Monday through Friday from 8:00 a.m. to 6:00 p.m., and Thursdays from 8:00 a.m. to 8:00 p.m. Call 1-800-462-5449 (TTY 1-800-655-1761) or send a fax 1-617-772-5512. The Clinical Operations staff is accessible to members seeking information about the UM process Monday through Friday 8:30 a.m. to 5:30 p.m. by calling 1-800-462-5449 (TTY 1-800-655-1761). You may leave a message or send a fax after hours. The lines are available 24/7. All messages left after hours will be read the next business day.