member news November 2016 FirstCare STAR & CHIP In this issue: Quality Improvement (QI) Program pg 2 Services Needing Approval pg 3 Case Management Services pg 3 Interpretation Services pg 3 FirstCare Extra Benefits pg 4 Expecting the Best Maternity Program pg 5 Talk to a Nurse Nurse24 pg 5 Advance Directives pg 5 1 Getting Answers to Your Questions pg 6 Tips on Seeing a PCP or Specialist pg 7
Quality Improvement (QI) Program Background FirstCare cares about you. No matter your age or your health plan, we want you to be happy with the care you get. FirstCare is always reviewing the care that we provide and working to improve it. Our goal is for you to stay healthy, illness-free, and satisfied with your care. We try to meet this goal by working closely with our staff and doctors to get you the best care. QI Program Methods FirstCare s QI program uses many ways to measure the quality of your care and your satisfaction. We set goals to improve our care and services. We check our progress toward those goals in areas such as: Quality of your care How easy and fast you get care Your health and ability to do daily living tasks Your views about your health care How well you and your doctor talk about your health care FirstCare uses quality scores, report cards, and surveys to assess our progress on goals. What We Do Well We re happy to say that we improved and/or did very well in several areas in 2015: Adult members had their weight checked in the last 1-2 years. Female members had a Pap smear in the last 3 years or Pap smear with HPV test in the last 5 years. (A Pap smear screens for cancer of the cervix. An HPV test screens for a viral infection of the cervix.) Members with diabetes had a kidney disease test or attention in the last year. Members with depression stayed on their medicine. Members with asthma were given proper medicine and stayed on it. How We re Improving Though we did well in a number of areas for 2015, we re working to improve in several other areas for 2016: Child members getting recommended vaccine shots. Members with diabetes getting an A1c test within the last year. (This test shows how well blood sugar levels are controlled.) 2
Services Needing Approval Do you want to know how to get care approved? Staff who decide on care are here to help you. We are here Monday through Friday from 8 a.m. to 5 p.m., except for state-approved holidays. Medicaid members should call FirstCare at 1-800-431-7798. CHIP members should call 1-877-639-2447. Persons who need TTY can call 1-800-562-5259. FirstCare decides about care based on how the care will affect your health needs and what your plan covers. FirstCare does not reward its staff for saying no to care. FirstCare does not reward its staff for keeping you from getting all of the care you need. FirstCare also uses standards to decide on care. You can get a copy of how we decide on care. Call the Customer Service number listed on your Member ID card and FirstCare will mail a copy to you. Case Management Services FirstCare has Case Managers here to help with your short- or long-term needs. Some of the help that a Case Manager can give include: Help with finding doctors that can meet your needs Help with getting community resources Help with learning about your health and how to manage it Help with understanding your benefits Help with children who grow up and need to find a doctor for adults FirstCare members can enroll in Case Management by emailing CaseMgmt@FirstCare. com or calling FirstCare Customer Service. Medicaid members should call FirstCare at 1-800- 431-7798. CHIP members should call 1-877-639-2447. Persons who need TTY can call 1-800-562-5259. You can refer yourself to this program. Find out more at my.firstcare.com. Interpretation Services If you, or someone you re helping, has questions about FirstCare Health Plans, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-866-245-1580 (TTY/TDD 1-800-562-5259). Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de FirstCare Health Plans, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-866-245-1580 (TTY/TDD 1-800-562-5259). 3
FirstCare Extra Benefits Wellness FirstCare helps you know how to take care of your health. We offer wellness programs. Online surveys to check your risk for disease Wellness trackers The Expecting the Best maternity program Long-term Conditions Other programs help you with long-term conditions. Asthma Heart disease Breathing trouble Diabetes Signing Up You can sign up online at my.firstcare.com or by calling 1.855.828.1013 (Monday - Thursday, 9 a.m. - 7 p.m. CT; Friday - Sunday, 9 a.m. - 6 p.m. CT). We also provide services to meet your special language needs please call 7 1 1 or 1.800.955.8771 using a TTY to take advantage of the relay service. Voice communication is available at 1.800.955.8770. You receive: Mailed flyers that explain how to take care of your condition Access to a nurse to answer questions and to teach you Tracking tools Health news online Online health education seminars These are all free of charge. 4
Expecting the Best Maternity Program The Expecting The Best Maternity Program is a free service offered to our pregnant members. It helps you to have a healthy pregnancy. There is no cost to you when you join FirstCare, and you ll get: Access to a nurse 24 hours a day, 7 days a week for questions about being pregnant, having a baby, and baby care Support after your baby is born Maternity reading materials Talk to a Nurse Nurse24 1-855-828-1013 Need care advice? Do you have health questions? Do you want to know about a drug? You can call the Nurse24 line and speak with a nurse about your health needs. This may help you gain peace of mind. The private call won t cost you a penny. Call 1-855-828-1013 to get the answers you need 24 hours a day, 7 days a week! TTY users users can call 7-1-1 or 1.800.955.8771. Voice communication is available at 1.800.955.8770. Plus, you ll get special gifts: A book about pregnancy Your Journey through Pregnancy Tools to help you track your pregnancy To join this free program, call 1.800.840.9629. TTY users can call 7-1-1 or 1.800.955.8771. Voice communication is available at 1.800.955.8770. Advance Directives The law says you have the right to decide about your care. If you are very sick or hurt, you may not be able to say what care you want. Advance Directives are legal forms. They allow you to say what you want ahead of time. This helps your doctor and family know what medical care you want. A good place to find out more about this, and to get the forms is online at www.caringinfo.org. Find out more at www.firstcare.com/important-information or call FirstCare Customer Service. 5
Getting Answers to Your Questions FirstCare covers many topics in your member handbook and on our website. We provide you with a handbook to help you know how your health plan works. Here is how you find your member handbook on our website: Go to FirstCare.com Under Individuals and Families, click on STAR Medicaid or CHIP Under Related Documents in the bottom right, click on STAR Member Handbook or CHIP Member Handbook The topics covered in your handbook include: Benefits and services that are part of your plan and not part of your plan How pharmacy is managed Charges that you may have to pay How to get care when you are out of First- Care s service area Coverage and benefit limits when you are out of FirstCare s service area Using an out-of-network provider What to do if you get a bill for services that should be covered How to find out about your doctors, such as how qualified they are How to get primary care How to get specialty care How to get hospital care How to get behavioral health care How to get care after normal business hours How to get emergency care How to submit a complaint or appeal Member rights and responsibilities How FirstCare considers new technology as a covered benefit We would like you to sign up for member selfservice on our website. This will let you get to info and tips more easily. To sign up, visit my.firstcare. com, click on Members, then Register Now. If you don t want to use the website, you may call our Customer Service Department. They will answer any questions you might have. They will also send you printed copies of info posted on our website that you would like. If there are any questions that are not answered in the handbook, Medicaid members should call FirstCare at 1-800-431-7798. CHIP members should call 1-877-639-2447. We are available Monday through Friday from 8 a.m. to 5 p.m., excluding state approved holidays. Persons who have hearing or speech problems and need TTY can call TTY 1-800-562-5259. 6
Tips on Seeing a PCP or Specialist Here are the timeframes our providers should meet for seeing FirstCare members: Type of Provider PCP or Specialist Type/Level of Care Treatment for urgent conditions, including urgent specialty care Time to Treatment (in calendar days) Provided within 24 hours PCP Routine care (child & adult) Provided within 14 days PCP Preventive health services newborns Offered within 14 days of member enrollment PCP Preventive health services new child members Offered within 90 days of member enrollment PCP Preventive health services adults Offered within 90 days Behavioral Health Initial outpatient behavioral health visits (child & adult) Provided within 14 days PCP or OB-Gyn Prenatal care (not high-risk) Provided within 14 days PCP or OB-Gyn High-risk pregnancies or new members in 3 rd trimester Offered within 5 days Several factors may increase the time period for you to get an appointment: Living in a rural area or particular area where there are fewer providers Disease outbreaks, such as flu, creating a large volume of patients scheduled at once Limited providers in general in a particular specialty FirstCare monitors member access to our providers. Where access issues are identified, FirstCare takes steps to address them. If you are not sure what type of care you need, you may call the Nurse24 line at 1-855-828-1013 (TTY/TDD 1-800-955-8770). If you have trouble finding a provider, call FirstCare Customer Service. Medicaid members should call FirstCare at 1-800-431-7798. CHIP members should call 1-877-639-2447. Persons who have hearing or speech problems and need TTY can call TTY 1-800-562-5259. If you have a true emergency, call 9-1-1 or go to your local emergency room. 7
12940 N. Highway 183 Austin, TX 78750 Thank you for being a FirstCare member! If you have any questions, please call FirstCare Customer Service at 1-800-431-7798 (Medicaid) or 1-877-639-2447 (CHIP). We are available Monday through Friday, 8 a.m. - 5 p.m. TTY users should call 1-800-562-5259. To access our Member Self-Service Portal, log on to my.firstcare.com or visit FirstCare.com and click on Member Log-In on the home page. MD/CH.memb.NL-Eng-11-2016 Health and Wellness 8 Information Inside