INSIDE: Medicare Stars Team Utilization Management New Member Portal Meals on Wheels Spring 2016 Message from the CEO Community Health Group is fast approaching our 34th anniversary. Time does fly incredibly swiftly when a company such as ours is always growing and adapting. Our company sprang from humble roots in the community health clinic movement and now, in a much changed health care environment, we continue to be committed to serving our members in San Diego County. We remain dedicated to providing you with quality care in a culturally sensitive manner. Providing exceptional service is our passion and ensuring that you receive access to quality care remains our mission. Our staff lives and works in your community, the community we serve. Being local means we interact with you our members and with our providers every day. Our staff is available to you 24-hours a day, seven days a week. And we have never forgotten that our membership is our most important asset; we take great pride in serving you and your family s health care needs. Community Health Group s 34th Anniversary MediCover-1 We want to thank you for your key role in our success and our longevity. And we promise to be true to our mission of serving you now and into the future. Mil Gracias Norma Diaz, CEO Community Health Group
Medicare Stars Team Community Health Group created a new team in April 2016. This team is dedicated to serving our Cal MediConnect members. We have 10 Medicare Service Specialists to help you with your health plan needs. The team members make home visits to help explain your health care benefits. If you have questions about your Cal MediConnect benefits or need any assistance accessing care, please call our MediConnect team for help! Cal MediConnect Team 1-888-244-4430 toll free 24 hours a day, 7 days a week Utilization Management Program How your health plan makes decisions Our decisions are based on making sure our members have appropriate care and services. Our decision-making is based only on: Is the care or service appropriate? Is the care or service a covered benefit of your specific health plan? When we deny a request for services, we send you and your provider a written notice. The notice states why the request was denied. (2)
Utilization Management Program We review and update the clinical criteria we use in making these decisions at least once a year or as needed. We add new developments in clinical practice to our criteria. We want our criteria to be up-to-date and appropriate for our health plan members. For more information about Utilization Management, call Customer Service. Have you heard the great news? You can now print your Member ID card, change your Primary Care Physician and update your address and phone number all in our new Member Portal! We know your time is valuable and that is why we eliminated the need for you to call Customer Service to address these issues. stantly thinking of new ways to service you better and faster. New Member Portal At Community Health Group, we want to provide you an opportunity to get your most common issues addressed quickly online. We are constantly thinking of new ways to service you better and faster. At Community Health Group, we want to provide you an opportunity to get your most common issues addressed quickly online. What can you do in the Member Portal? 1. Print a Member ID card. You can print a new Member ID card anytime with access to a printer, of course! 2. Change your Primary Care Physician. Review the online list of Primary Care Physicians. Select the physician you want. Print a new Member ID card that shows your new physician sname. 3. Update your address or phone number. It s easy to update your address and phone number. We need your current address and phone number at all times to give you the best care and service possible. How to access the Member Portal Go to www.chgsd.com and click the button Member Login. Click the Register button and fill in the fields marked with an asterisk (*). Click the Submit button. Create your login information (username and password). You are now in the Member Portal and can use the services we mentioned above. (3)
Community Health Group teams up with Meals on Wheels for Birthday Meals! Starting April 2016, CHG began offering home delivered meals to Cal MediConnect members in their birthday month. In the month of April, CHG employees and Meals on Wheels volunteers had the opportunity to deliver meals to Cal MediConnect members with a birthday in April. Members were very appreciative of the meal and the volunteers were very happy to provide the service! Quotes: Thank you very much young lady! This is very sweet of you. You are making me feel very special! April Birthday member To me, it was very rewarding, the member was very thankful for the meal, and she had a few questions about her benefits, so I was able to help her with that as well! Elizabeth Subia, Medicare Services Specialist (4)
Why it s Important to control your blood sugar How to tell if your diabetes is under control TAKE CONTROL OF DIABETES Take control of diabetes! (5)
June is Cancer Awareness Month Finding and treating cancer early is the best way to beat this disease! To help you stay healthy, our members have access to these women s health services: MAMMOGRAM this test detects breast cancer. Mammograms are recommended every two years for women ages 40-50 and every year for women 51-75. PAP SMEAR this test detects cervical cancer and some sexually-transmitted diseases. We recommend this screening every three years for women 21-65. ANNUAL DOCTOR VISITS please see your doctor every year to talk about your overall health. Your doctor s office will help you keep track of when you should have your mammograms and Pap smear. Please call Member Services if you have questions about your health plan benefits. We can also help you set up a doctor s appointment. Customer Service 24 hours a day/7 days a week 1-888-244-4430 (6)
Prevent Osteoporosis Osteoporosis makes your bones weak and more likely to break. It is a disease of the bone. One in two women and one in four men will break a bone during their life because of osteoporosis. Building strong bones during childhood can help prevent osteoporosis later in life. There is no cure but there are things you can do to prevent, slow or stop its progress. 1. Age 50 and older, get enough calcium (1,200 mg) and vitamin D (800-1000 IU s) every day. Foods with lots of calcium are: milk, yogurt, cheese, broccoli, and oranges. For vitamin D: tuna, salmon, liver and egg yolks. 2. Do regular weight-bearing (dancing, walking, running, hiking) and mucle-strengthening (lifting weights/using weight machines) exercises. 3. Do not smoke or have more than two alcoholic drinks a day. 4. Talk to your doctor about your chances of getting osteoporosis. Ask when you should have a bone density test. A bone density test is the best way to see if you have osteoporosis. 5. Take the osteoporosis medication when recommended by your doctor. (7)
Telephone Advice Nurse Our Telephone Advice Nurse is like having a nurse in the family! Call our nurses with your questions: How to take care of a problem at home Where to get urgent care How to get a prescription filled Telephone Advice Nurse 24 hours a day, 7 days a week 1-800-647-6966 ER or Urgent Care? When to go to It can be hard to decide where to go if you or your child needs quick medical care. Should you go to the Emergency Room or an Urgent Care Center? When to go to the emergency room: An emergency is a medical problem or injury that puts a person s life in danger. Some examples: Bleeding or vomiting that does not stop Loss of consciousness Poisoning Chest pain Major burns Trouble breathing Choking Head injury Minor sprains Ear ache Fevers, colds or bronchitis Insect bites Mild asthma attacks Diarrhea Minor cuts Back pain In a medical emergency, go to the nearest Emergency Room or call 911. Please keep in mind that we have the right to request that you dis-enroll from our health plan if you use the ER for non-emergency services. Telephone Advice Nurse 1-800-647-6966 Customer Service 1-888-244-4430 (8)
How long do you have to wait for an appointment? Type of appointment Routine doctor visits Physical exams and wellness checkups Initial Prenatal visit Standard Specialty care Urgent care In an emergency, call 911 or go to the nearest emergency room. Please call Customer Service if you have waited too long for access to health care. Medical Bills If you get a medical bill in the mail, don t ignore it! Call Customer Service. We will find out why you received the bill and help resolve the issue. If the bill is for a service covered by your health plan, you should not be billed. Don t let unpaid medical bills get reported to a collection agency and show up on your credit report. Call Customer Service as soon as you can. Call Customer Service 24 hours a day, 7 days a week 1-888-244-4430 Your Drug Benefit Community Health Group has a formulary for each health plan we offer. A formulary is a list of drugs that are covered by your health plan. We review and revise this list at least four times per year to stay up-to-date. Financial Incentives The decisions we make about the care and services you receive are based on making sure you have appropriate care and services. The Utilization Management decisions our team makes are based on two factors: Is the care or service appropriate? Is the care or service a covered benefit of your health plan? We do not reward practitioners or others for denying coverage, service or care. Any financial incentives for Utilization Management decisions do not encourage decisions that result in underutilization. For more information, call Customer Service. To see the current formulary for your health plan: Visit our website at www.chgsd.com, or Call Customer Service to have a copy mailed to you. For questions about your formulary or drug benefit, call Customer Service. (9)
Report Health Care Fraud! Help us save valuable health care resources by reporting fraud. If you think a Community Health Group employee, member or provider is involved in fraud, we urge you to report it. A COUPLE EXAMPLES OF FRAUD ARE: Using someone else s card to get care or services. Doctors giving care that is not needed Please report anything that does not seem right to you. Fraud & Abuse Hotline 1-800-651-4459 You can leave a message 24 hours a day, 7 days a week. Your Privacy The privacy of your Protected Health Information is important. We safeguard this information as it is collected, used and disclosed. We protect information that is spoken, written or put into electronic form. These rules apply throughout our health plan and at provider offices. We use and disclose your health information to: Provide treatment Pay providers for health care services Conduct usual health plan operations. If we want to share information with anyone else or for any other reason, we ask your permission in writing. The only exceptions are those required or allowed by law. You have the right to: Limit the use and sharing of your Protected Health Information beyond the reasons of treatment, payment or usual health plan operations. Review your health information and ask for amendments or additions to it. Ask for a list of providers or others we have shared your Protected Health Information with. Receive a copy of our Notice of Privacy Practices. (10)
Your Rights & Responsibilities as a Health Plan Member MEMBER RIGHTS You have the right to: Get information about CHG, its services and its doctors and other doctors in a way that may be easily understood. Get information about your rights and responsibilities as a CHG member. Be treated with respect and dignity. Privacy. Choose a primary care doctor from within our network of contracted doctors. Participate with your doctor in decision making about your health care, and to refuse treatment. An open and honest discussion of your treatment options in spite of cost or health plan benefits. Get appointments within a reasonable amount of time. Complain about CHG or the care you have gotten. Appeal when you don t agree with a decision CHG has made. Ask someone to explain or translate if you don t understand something that is said or written. Providing translation services would be at no cost to you. Request an interpreter at no charge to you. Use interpreters who are not your family members or friends. File a complaint if your linguistic needs are not met. Prepare Advance Directives. Have your health records kept private. See your health records. Make recommendations about CHG s rights and responsibilities policies. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Exercise these rights without adversely affecting how you are treated by CHG, its doctors, or the State. Member Name: Member ID: Health Plan (80840): Date of Birth: Effective Date: PCP Name: PCP Phone: H5172_IDCard_2015 Approved 12/8/14 RxBin: RxPCN: RxGRP: (11)
Customer Service Dept. #23 2420 Fenton Street, Suite 100 Chula Vista CA 91914 Change Service Requested PRSRT STD U.S. POSTAGE PAID PERMIT NO.2114 SAN DIEGO, CA Y R & R Your Rights & Responsibilities as a Health Plan Member MEMBER RESPONSIBILITIES You have the responsibility to: Keep follow-up visits with your doctor. Tell your doctor if you don t want to follow a treatment plan. Make and be on time for health appointments or cancel appointments at least one business day ahead of time. Treat all CHG personnel and health care doctors respectfully and courteously. Go with your children who are under age 18 (if they are enrolled in the plan) when they are getting health care. You can sign a form that allows the child to be treated without you there. Help CHG maintain accurate and current records by providing timely information about changes in address, family status and other health coverage. Notify CHG as soon as possible if you get a doctor s bill or if you have a complaint. Give correct information to CHG, its doctors and other doctors so that they can care for you. Follow the plans and care directions that you have agreed to with your doctor and others who provide care to you. Know your doctor s name. Present your member ID card(s) when getting health care. If you have other insurance, take that card too. Use emergency services only in cases of an emergency or as directed by your doctor. Remember what your doctor tells you about your health problem. Understand your health problems and participate in developing treatment goals. Ask questions if you don t understand what you are told. (12)