Balance Winter 2019

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W I N T E R

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I really see one of my roles in the future is to give young women the same opportunities I’ve had.

Network Health member, Jes Davies, discussing her role as a physical therapist and yoga instructor.

Inside Page 4 The Importance of Your Annual Wellness Visit Page 16 The Hidden Dangers of Electronic Cigarettes Page 23 Important Pharmacy Network Updates

P U B L I C A T I O N

O F

L I F E , H E A LT H & W E L L N E S S

3 Letter from the President and CEO

04

4 The Importance of Your Annual Wellness Visit

E DITORIAL STAFF

5 Understanding HMO Health

Insurance Plans

Chief Administrative

Officer Penny Ransom

5 How Health Plans Make Decisions

Strategic Marketing and Communications Coordinator Becky Pashouwer

6 Protecting Your Health Information

Visual Design Lead Debra Sutton

6 Your Right to Request an

E DITORIAL

Independent Review

7 Take Advantage of One-on-One Care Management

COVER STORY

20

08

18 Where should you go—

Emergency Room, Urgent Care or Virtual Visit?

19 Need a Health Coach?

A Lifestyle of Wellness

on Quality

20 Is It More Than the

Wintertime Blues?

21 Jargon Decoder 22 New $25 Insulin Program

13 What is Population

22 Are You Using Antibiotics

13 Clinical Practice Guidelines

23 Important Pharmacy

Health Management?

14 The Service You Deserve 15 Evaluating New Technologies 16 The Hidden Dangers of

BOARD

Melanie Draheim, Angela Keenan, Joan Merwin, Mallory Mueller, Alice Parks, Stacy Schwandner, Romi Norton, Kimberly Swanson, Theodore Regalia, Kacey Werner, Hannah Zillmer Balance is published by Network Health.

The health information contained in Balance is meant to supplement, not replace, the advice of health care professionals. © 2019 Network Health. No portion of this newsletter may be reproduced without written permission from Network Health.

12 Network Health Rates High

President Coreen and CEO Dicus-Johnson

Electronic Cigarettes

Properly?

Network Updates

23 Approaching 65?

Network Health has you covered.

24 Doctor Visits From the Comfort

of Your Home

Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-826-0940.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-826-0940.

Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 800-826-0940.

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TELL US YOUR STORY If you have questions or suggestions or would like to tell us how Network Health improved your life, send us an email at

marketing@networkhealth.com.

You can also write to us at: Network Health Attention: Jon Race 1570 Midway Pl. Menasha, WI 54952

HAVE A QUESTION?

Call our highly-rated customer service team.

HOURS Monday, Wednesday–Friday: 8 a.m. to 5 p.m.

Tuesday: 8 a.m. to 4 p.m.

PLANS THROUGH AN EMPLOYER 800-826-0940 PLANS FOR INDIVIDUALS AND FAMILIES 855-275-1400 STATE OF WISCONSIN EMPLOYEES/MEMBERS 844-625-2208 Monday, Wednesday–Friday: 8 a.m. to 5 p.m.

Tuesday: 8 a.m. to 4 p.m.

WANT MORE HEALTH TIPS? Check out our blog at copilotwi.com.

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life. health. wellness.

Letter from the President and CEO I would like to take this opportunity to thank you for being a Network Health member.

Network Health is built on the foundation of a local health plan bringing high-quality care and exceptional service to its members. This edition of Balance includes a variety of informational articles on programs available to you as a member of Network Health. I hope you can take advantage of some of these programs in the coming year.

The feature story is from one of our in-network providers who is also a Network Health member.

Her story highlights the important role wellness has played in her personal life and how she is sharing that knowledge with her patients in her professional life.

The trust you place in Network Health is very much appreciated. We look forward to another year of providing exceptional one-on-one service.

From all of us at Network Health – have a happy and healthy new year.

Sincerely,

Coreen Dicus-Johnson President and Chief Executive Officer

HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health Insurance Corporation or Network Health Insurance Corporation and Network Health Plan. Self-insured plans administered by Network Health Administrative Services, LLC.

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The Importance of Your Annual Wellness Visit

By: Devon Lor, MSN, RN, Quality Health Integration Clinical Supervisor

S

eeing your personal doctor (also called your primary care practitioner or PCP) for an annual wellness visit early in the year is a great first step to managing your health and creating healthy goals. An annual wellness visit is primarily focused on preventive care, health screenings and wellness planning. Your personal doctor will also review your medical history, discuss medications you are taking, record your height, weight, blood pressure and other routine measurements. This visit gives you an opportunity to have a conversation with your doctor about your health status, health goals and create a plan to help you maximize your well-being throughout the year. Because your annual wellness visit is such an important part of your health care, Network Health covers this visit at no charge, when you see an in-network doctor.

Understanding the difference between preventive and diagnostic screenings is beneficial, because it explains why you may need certain care, services or screenings, and when your visit may become diagnostic and have a cost associated with it.

PREVENTIVE SCREENINGS

DIAGNOSTIC SCREENINGS

Your doctor will order preventive screenings when you have no symptoms and are generally healthy.

These screenings are recommended by your personal doctor every year to keep tabs on your health and keep you healthy.

Diagnostic screenings are used when you have symptoms or risk factors, to find and treat the problem. If your doctor finds anything abnormal during your preventive screenings, he or she may order diagnostic screenings to detect any problems.

Covered at no charge to you

You may have out-of-pocket costs

If your doctor orders tests during your annual wellness visit and you’re not sure if they’re considered preventive or diagnostic, just ask. Your doctor will let you know which screenings are preventive, which are diagnostic and why each test is being ordered.

Get an early start on improving or maintaining your health this year. The sooner you have your annual wellness visit and discussion with your personal doctor, the sooner you can make a difference in your health. Call your doctor today to schedule your annual wellness visit.

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networkhealth.com

Understanding HMO Health Insurance Plans

H

MO may sound like insurance jargon, but it’s important to understand what it means if your Network Health plan is an HMO.

HMO stands for Health Maintenance Organization. This type of health insurance plan includes a select group of in-network providers that are available to you. As a member of an HMO health plan, you must receive care from these in-network providers, because HMO plans don’t cover out-of-network care, except in an emergency.

How to Use Your Network Health HMO Plan

If your Network Health plan is an HMO, you select in-network doctors, hospitals, clinics and specialists for services to be covered under your health plan. You can find in-network doctors at networkhealth.com/ find-a-doctor. If you use an out-of-network facility or provider for health care services, you will be financially responsible for the full cost of the services, unless you receive prior authorization from Network Health.

What’s Prior Authorization?

As a member of Network Health, you can see in-network doctors without a referral.

Select services require approval (called prior authorization). If you are referred to an out-of-network doctor for any services (excluding emergency services), you—as the member—must obtain prior authorization before the appointment.

The purpose of prior authorization is to ensure you are protected from unnecessary care and you are receiving safe and effective treatment.

For questions or to obtain a prior authorization, please contact Network Health’s Utilization Management Department at 800-236-0208.

How Health Plans Make Decisions

U

tilization decisions made about care by Network Health are based on the appropriateness of care and service, including medical procedures, behavioral health procedures, medications and devices. Decisions are based on written criteria, which are based on sound clinical evidence and the benefits outlined in your coverage documents. The written criteria are reviewed and approved annually by active practitioners. Criteria are available to you and your doctors upon request. Requests for criteria can be submitted electronically, by phone, fax or mail. Once the request is received, someone on Network Health’s care management team will send the requested criteria to you electronically, via fax or mail.

Network Health does not reward practitioners or other individuals conducting utilization reviews for denying coverage of care or service. In addition, Network Health does not prohibit providers from advocating on behalf of you within the utilization management program. Network Health does not use incentives to encourage barriers to care and service, and we do not make decisions about hiring,

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promoting or terminating practitioners or other associates based on the likelihood, or the perceived likelihood, that the practitioner or associate supports, or tends to support, denial of benefits. The medical directors, associates (or designees), care management staff and supervisors of this staff receive no financial incentive to encourage decisions that result in underutilization.

In addition, practitioners may discuss medical necessity denial determinations with the physician review medical director by contacting us at 920-720-1600 or 800-236-0208 (TTY 800-947-3529).

For questions specific to behavioral health utilization, they can call 920-720-1340 or 800-555-3616 (TTY 800-947-3529). Bilingual language assistance or translation services are also available. Callers may leave a message 24 hours a day, seven days a week. All calls are returned promptly. Calls received after business hours are returned the next business day. Members, practitioners and/or providers may also send inquiries to the care management department via fax, courier system or mail.

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Protecting Your Health Information

H

ealth Insurance Portability and Accountability Act (HIPAA) regulations prevent Network Health from talking to another person about your health insurance coverage or care—including your spouse and children—even if you’re on the same policy. One of the main goals of the law is to protect the confidentiality and security of personal health information. That is important to us, but we also understand you may want or need someone else to access your information.

By completing our Protected Health Information Form, you can give us permission to share your personal health information with a designated person(s) for two years.

In the case of minor children, parents must have consent when requesting information about certain types of care when the child meets a specific age. Below is a table that outlines the age a minor’s consent is required to provide information about health care services.

Type of Care

Age that the minor’s consent is needed

Alcohol or Other Drug Abuse

Age 12 or older

Developmentally Disabled

Age 17 or older guardianship papers are needed

HIV Test Results

Age 14 or older

Mental Health

Age 14 or older

Contraceptive Care

Age 12 or older

Newborn Care (Parent is a Minor)

In general, once the minor has delivered her child, as the parent, she is the legal representative for the child and may authorize disclosure of PHI. This means the parents of the minor child cannot be given PHI about the baby (grandchild) without the mother’s consent.

To access the Protected Health Information Form, visit networkhealth.com and choose the Employer Plans tab if you get coverage through your employer or the Individual and Family Plans tab if you buy insurance on your own. Select Member Resources from the dropdown.

Under Forms, you will find the Protected Health Information Form. You can mail your completed form to Network Health, P.O. Box 120, Menasha, WI 54952.

Your Right to Request an Independent Review W

e work hard to ensure your satisfaction, but it’s important to know you have the right to request an independent organization examine certain final decisions made by Network Health. Reviews are completed at no cost to you. Decisions eligible for review are those where Network Health determined the requested care or services did not meet our requirements for the following.

•

•

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Medical necessity (care that is reasonable, necessary or appropriate based on proven clinical standards) Health care setting

• Level of care • Effectiveness • Experimental treatment • Appropriateness • Cancellation of a policy or a certificate • Coverage denial determination based on a pre-existing condition exclusion For more information about the independent review process at Network Health, refer to your certificate of coverage, policy or contact our customer service department at the phone number listed on the back of your member ID card.

networkhealth.com

Care managers are available by calling 800-236-0208, Monday–Friday, from 8 a.m. to 5 p.m.

Take Advantage of One-on-One Care Management By: Alice Parks, Director of Population Health

N

etwork Health offers care management services to you at no additional cost. Through this program, experienced nurses and social workers, also known as care managers, can support you with the following.

Improving your overall health Navigating the health care system Coordinating community resources Getting needed services in optimal, cost-effective settings Transitioning from hospital to home

If you are eligible and agree to participate, you can be enrolled into a program.

Once enrolled, a care manager works with you to identify your health care needs, develop goals based on your values and helps you meet those goals.

If you have complex chronic conditions or illnesses that could lead to high-risk conditions or an increased use of health care services, you may benefit from care management. These conditions could include any of the following.

Complex chronic diseases, such as metastatic cancer or end-stage renal disease Catastrophic or rare conditions, such as premature infancy, high-risk pregnancy, trauma or spinal cord injury Conditions requiring an organ or stem cell transplant Major complications from a surgery or an extended hospital stay Multiple physician specialists involved in care Multiple specialty equipment needs at home

In addition, a care manager may reach out to you when you are discharged from a hospital stay to go home. The care manager will review your current medications, planned follow-up visits with doctors, and other instructions with you to ensure a smooth transition.

If you think you could benefit from care management, you can be referred to us by your personal doctor, a hospital case manager or discharge planner, your caregiver or you can refer yourself. Network Health may also identify you as a candidate for services through our claims or utilization processes.

You can enroll in a program or opt out of a program by calling 800-236-0208 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 5 p.m. Ask for a care manager.

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“

I’m working with individuals to make things easier all the way around.

“

Yvonne, RN Nurse Care Manager at Network Health

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Jes and Melanie Landgraf, owner of Tosa Yoga Center, demonstrate a partner yoga pose 8 | balance • W i n t e r 2 01 9

networkhealth.com

A Lifestyle of Wellness

By Becky Pashouwer Photographs by Beth DesJardin, Trove Photography

F

rom the time she was young, Network Health member Jessica Davies always knew wellness would play a role in her life. “I don’t remember a lot from high school, but I do remember my high school guidance counselor. He was the one who sat me down and suggested I be a physical therapist,” said Jes. As a high school athlete who enjoyed the sciences, especially biology, she decided that was the right path for her. Jes worked hard to get into UW-Madison’s physical therapy program and put herself through college. Her hard work and dedication led her to a career that allows her to share her passion for wellness with members of her community.

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When Jes graduated from college, she was the heaviest she had ever been.

To get herself back on track, she joined the Wisconsin Athletic Club (WAC) to take fitness classes. The facility was new, so they needed teachers. Jes decided to give it a try. She loved teaching kickboxing, spin and bootcamp classes. “After a few years of teaching, the WAC made me get my yoga certification. I went kicking and screaming,” Jes laughed. “In the end, it was a huge blessing to me. That’s where I learned that food is fuel and by choosing vegetables and protein I wasn’t depriving myself but making better choices.” Once she incorporated these changes into her life, she quickly saw a positive impact, in both her weight and the way she felt.

During her first five years out of college, Jes worked in Froedtert’s Cardiopulmonary Rehabilitation Program. She enjoyed the fast-paced environment and the constant learning experiences. When she started a family, she transitioned to home care because it gave her the schedule flexibility she needed. As her children got older, she searched for a new opportunity. Jes said, “I asked myself, what do I really want to be doing with my time? That’s when I transitioned into private practice.”

Today, Jes owns a private practice within Body Renovation, a sports medicine and orthopedic rehabilitation center that works one-on-one with patients to develop a plan for quick recovery. Because she’s divorced and self-employed, she purchases her health insurance plan through the health insurance exchange. Jess explained, “When my household was separating, I was fearful about the insurance side of things. I was very concerned about what my options were going to be for health care, being a cancer survivor.”

Jes was put in contact with an insurance agent who walked her through the available plans. “My care was established at Froedtert, so as I looked at policies, I needed one that included Froedtert as a provider,” Jes said. After reviewing her plan options, Jes selected Network Health. She said, “Over the last three years, I’ve never had a bad experience. I think that’s a very positive thing, because I watch patients go through appeals processes for procedures that are medically necessary and should be covered. I’ve never had anything like that happen at Network Health.”

Over the last three years, I’ve never had a bad experience. I think that’s a very positive thing, because I watch patients go through appeals processes for procedures that are medically necessary and should be covered. I’ve never had anything like that happen at Network Health.

At Body Renovation, Jes is a licensed physical therapist with several certifications, including functional manual therapy, manual trigger point therapy and strength and conditioning coaching. Most of Jes’ patients are active individuals who are experiencing pain, loss of motion, inability to perform in sports and want to get back to their active lifestyle.

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networkhealth.com

After going through breast cancer treatment in 2014, Jes wanted to help other women, so she pursued additional education and added a women’s health emphasis to her practice. About one third of her caseload revolves around women’s health. This can be anything from pre- and postnatal care to unresolved pelvic pain. “I’m like a special investigator who fixes the things we don’t normally think are affecting our everyday function,” said Jes.

I’m like a special investigator who fixes the things we don’t normally think are affecting our everyday function.

Yoga, I meet a lot of people who are very proactive in their health and wellness. So, people who want to talk about what’s hurting, but also want to talk about movement, nutrition, weight management and stress management.” She continued, “When people come to me, they know that they get a more comprehensive look at their health than they would from a gym.”

As Jes looks to the future, she wants to give back to her community.

She said, “I really see one of my roles in the future is to give young women the same opportunities I’ve had. I like the idea of doing more teaching and more mentoring and eventually growing my practice in a way where I can bring a few women on board with me.”

Jes shares an office with Dr. Sarah Smasal. They both believe in a comprehensive care approach, which can include bringing other providers into a patient’s care. “Over lunch hours, we bring in outside providers to help us understand what they do,” Jes said. By making these connections, Jes meets other providers in the area and learns who she can partner with to treat a patient.

Jes has found that many times nutrition is an obstacle for people.

She knows how important it is to inform people about making better food choices, so they feel more energized and recover from injury more quickly. Luckily, most people are aware they need to work on nutrition and are open to making a change. “Sometimes it comes down to simple things,” Jes said. “Some people really need a one-onone person. I work with individuals who are metrics driven and need a set of rules to follow, and I work with other individuals who want to go shopping together and understand where patterns are coming from.” Her goal is to create individualized care plans based on the methods that work best for a person.

In addition, Jes understands financial barriers may cause people to forgo care when they’re in pain. Because she gets so many referrals and is active in the Wauwatosa community, she knows a lot of people in the area. “There are people who sit down in my chair, and I’ll say, ‘I know right now you don’t have the money to be here. Let’s develop a plan and we’ll be smart with our time and space out our visits.’ Then I let them slowly pay off their bill,” said Jes. One of the reasons Jes enjoys being a business owner with low operating costs is because she has the freedom to ensure people can afford to get the services they need. “I am highly committed to keeping my costs affordable, so everybody has the possibility of getting better,” Jes said.

Jes’ passion for movement and knowledge of anatomy are also reflected in her personal life. She is the assistant program director at Tosa Yoga Center, a family-owned business on the east side of Wauwatosa that focuses on providing an environment for individuals to work toward happiness and well-being. As the assistant program director, Jes teaches yoga and trains instructors. “Through Tosa

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Network Health Rates High on Quality T

he National Committee for Quality Assurance (NCQA) uses two nationally recognized evaluation tools to assess the quality of care and services provided to you through your Network Health plan—the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®).

Each test scores our services in a different way. HEDIS measures preventive care and care for chronic diseases. CAHPS evaluates your satisfaction with services provided by customer service, claims and physicians.

The tables below show Network Health’s excellent results on both state and national levels.

How We’re Doing

2019 Reporting Year Network Health HMO/POS (Commercial) HEDIS Results

Category/ Measure Colorectal Cancer Screening Controlling High Blood Pressure Comprehensive Diabetes Care – Eye Exams Comprehensive Diabetes Care – Controlled HbA1c (Less than 8.0 percent) Prenatal Care Post Partum Care

Network Health Results

Wisconsin Health Plans Average Results

National Average Results

72.51%

65.33%

62.10%

71.29%

63.50%

54.68%

69.89%

54.55%

52.58%

66.42%

54.22%

54.48%

98.26%

81.33%

82.10%

91.86%

Childhood Immunization Status 64.14% – Combo 10 Immunizations for Adolescents 84.75% – Meningococcal Conjugate

77.93%

72.52%

60.31%

52.32%

81.18%

80.31%

Immunizations for Adolescents - Tdap

93.00%

91.17%

86.98%

Well-Child Visits for Ages 3-6

82.71%

78.98%

77.41%

How You Rate Us 2019 Reporting Year Network Health HMO/POS (Commercial) CAHPS Results

Network Health Results

Wisconsin Health Plans Average Results

National Average Results

How often did you get an appointment to see a specialist as soon as you needed?

88.30%

83.94%

83.81%

How often did your personal doctor seem informed and upto-date about the care you got from these doctors or other health providers?

88.30%

85.43%

83.13%

How often did your health plan handle your claims correctly?

91.40%

91.40%

90.97%

How often did your personal doctor explain things in a way that was easy to understand?

97.00%

97.42%

96.39%

How often did your personal doctor listen carefully to you?

97.00%

96.06%

95.11%

How often did your health plan’s customer service staff treat you with courtesy and respect?

96.60%

96.11%

95.37%

Category/ Measure

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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networkhealth.com

What is Population Health Management?

By Alice Parks: Director of Population Health Management

T

he goal of population health management is to improve a group’s health outcomes by monitoring and identifying individual patients within that group.

Network Health’s population health strategy is designed to support our mission of creating healthy and strong Wisconsin communities by doing the following.

• Enhancing our member experience • Improving the quality and engagement of clinical management • Providing proactive support to our members • Promoting continuity of care and cost effectiveness through understanding the needs of all Network Health members

Each of these areas of focus offer at least one program or service that is available to members within the target population. This population may be based on current diagnosis, risk factors, member-identified areas of interest or other health factors.

For more information about Network Health’s Population Health Programs, email QI@networkhealth.com.

The population health strategy focuses on these areas.

• Keeping members healthy • Managing members with emerging risk • Patient safety or outcomes across settings • Managing multiple chronic illnesses

Clinical Practice Guidelines

N

etwork Health provides clinical practice guidelines to help you and your health care team make decisions regarding appropriate care for specific circumstances. These guidelines are selected after careful consideration by a panel of physicians on Network Health’s Medical Policy Committee. Guidelines are available for conditions that may be medically acute or chronic in nature, such as low back pain, diabetes, tobacco cessation or depression. These guidelines are updated as new ones become available.

These evidence-based guidelines are available to you and your doctors on Network Health’s website. To access them, go to networkhealth.com and click the Employer Plans tab. From the dropdown, choose Member Resources. Select the Clinical Practice Guidelines link under the Additional Resources heading. To view the guidelines for a specific condition, click the condition and you will be redirected to a page containing the appropriate information.

If you would like a printed copy of these guidelines, call our customer service department at the number listed on the back of your member ID card.

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THE

service deserve YOU

A

t Network Health, we want to ensure you’re receiving the service you need and deserve. If you have concerns, we want to make sure you understand all your options. If you do not agree with Network Health’s decisions about your care or what’s covered, you have the right to file an appeal or grievance. We have a team of appeals and grievance specialists who will work with you throughout this process.

When do I ask for a reconsideration?

If you would like to request a reconsideration—which is a rereview of your claim—you may call our customer service department at the number listed on the back of your member ID card.

If you request a claim review, Network Health will complete a second review of your claim and will provide you a decision once the review is complete.

If Network Health still denies your claim—referred to as upholding the denial—you will receive a written notification with the specific reason(s) for the continued denial.

When do I file a grievance?

You have the right to file a grievance if you do not agree with Network Health’s decisions about your health care. You can submit a grievance in writing within 60 calendar days of the date you receive a claim denial. Your written grievance should include your full name, member ID and detailed information about the decision you would like reviewed. You may also include any comments, documents, records or other information you would like Network Health to consider in its review.

Examples of situations appropriate for a grievance include the following.

Network Health will not approve care you believe it should cover.

Network Health is ending coverage on care you still need.

Network Health has denied payment for services or items you have received and you think they should be covered.

S AY W H AT ?

Pre-service claim is prior authorization of a service or procedure

Post service claim is a claim that is processed after the service has been performed

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Who may file a grievance?

You or someone you name to act for you (called your representative) may file a grievance. To name your representative, visit networkhealth.com and go to the Member Resources page (under Employer Plans if you get coverage through your employer or Individual and Family Plans if you buy insurance on your own).

Complete the Appointment of Representative Form and send it to the address listed on the form.

What happens after I file a grievance?

When you file a grievance, you are formally requesting Network Health to review our decision. We will acknowledge your grievance within five business days of receiving it. The Grievance Committee will schedule a hearing to review your case and you will be notified at least seven days prior to that meeting. Before the meeting, you have the right to submit written comments, documents, records and information relevant to your grievance. You may attend the grievance meeting in person or on the phone to present any additional information. After the hearing, the Grievance Committee will address your grievance and provide a written response within 30 calendar days for a preservice claim or 60 calendar days for a post-service claim.

How are medication grievances handled?

Medication grievances should be submitted in writing and are reviewed by a Network Health pharmacist and Network Health medical director, as needed. The pharmacist communicates with the prescribing provider if additional information is needed or discusses alternative covered medications. Our pharmacists strive to address medication appeals within four hours and have been successful over 90 percent of the time.

When do I file a complaint?

If you’re dissatisfied with the service or quality provided by your plan or doctor, we can help you work through any issues. You have the right to file a formal complaint about the service you received from Network Health, our vendors or contracted providers.

These are examples of situations that are appropriate for a grievance.

Difficulty getting through on the phone

Concerns about the quality of care or services provided

Interpersonal aspects of care (for example, rudeness of a provider or staff)

Failure to respect your rights

networkhealth.com

Evaluating New Technologies N

etwork Health’s Medical Policy Committee (MPC) evaluates new technology or new ways of using existing technologies on a regular basis. The evaluation process considers effectiveness of the technology, its appropriate use and evidence base.

Making decisions about technologies is based on, but not limited to, the following.

n Scientific evidence demonstrated in well-designed and well-controlled studies published in peer-reviewed literature

n Information from appropriate government regulatory bodies—such as the Food and Drug Association and/or the Centers of Medicare and Medicaid

Services

n Risk/benefit analysis as compared to current methods

n Manufacturer information

n Assessments done by agencies specializing in technology assessments— such as the Blue Cross and Blue Shield Association Technology Evaluation and

Coverage Program

n Opinions of provider experts When a new technology or application is found to be safe and effective, the MPC develops necessary criteria for its application. If it isn’t already covered, our strategic committees consider including the technology in coverage documents.

The following technology assessments have been completed over the past 12 months.

Technology Review

Outcome

Home phototherapy for the treatment of psoriasis

MPC decided this technology is safe and effective. Network Health has developed a medical policy.

N-Telopeptide NTx, Urine (urine test to check bone density)

This technology will continue to be reviewed under Network Health’s potentially experimental/ investigational/unproven process using the agencies Hayes and MCG. Final determination review is done by a Network Health medical director.

CardioMEMS (pulmonary artery monitoring for individuals with class III heart failure)

This technology will continue to be reviewed under Network Health’s potentially experimental/ investigational/unproven process using the agencies Hayes and MCG. Final determination review is done by a Network Health medical director.

ClariVein (treatment for varicose veins)

This technology will continue to be reviewed under Network Health’s potentially experimental/ investigational/unproven process using the agencies Hayes and MCG. Final determination review is done by a Network Health medical director.

dHACM (injectable for the treatment of plantar fasciitis)

This technology will continue to be reviewed under Network Health’s potentially experimental/ investigational/unproven process using the agencies Hayes and MCG. Final determination review is done by a Network Health medical director.

MPC members, Network Health providers and/or health plan employees may submit requests for technology assessments. If you have a question about a technology assessment, call our care management department at 800-236-0208 or 920-720-1600 Monday–Friday, from 8 a.m. to 5 p.m.

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The Hidden Dangers of

Electronic Cigarettes By: Jennifer Stubbe, CWP, Health Coach Specialist at Network Health

E

lectronic cigarettes are a hot topic. They are also referred to as e-cigarettes, vapes, e-hookahs, vape pens, tank systems, mods and electronic nicotine delivery systems (ENDS). Most commonly, the act of using one is called vaping. The look and style of an e-cigarette varies greatly. Some look like a typical cigarette, cigar or pipe while others mimic pens, USB sticks and other common daily items.

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E-cigarettes work by heating liquid to produce an aerosol that the user inhales into his or her lungs. The exhaled air from a user may also be inhaled by bystanders. The liquid used in an e-cigarette varies significantly. The liquid may contain these ingredients, and more.

Nicotine Tetrahydrocannabinol (THC) - the mind-altering compound in marijuana Cannabinoid (CBD) oils Synthetic flavorings Volatile organic compounds Cancer-causing chemicals Heavy metals Other additives and non-regulated substances Exposure to nicotine from e-cigarettes varies, depending on the device, the liquid and how the device is operated.

The initial purpose of the e-cigarette was to provide adult smokers with an alternative method to assist with quitting nicotine, when used as an exclusive substitute for traditional cigarettes, cigars or pipes. However, they are not approved by the United States Food and Drug Administration (FDA) as a safe aid to tobacco cessation.

Thus, there aren’t regulations in place to ensure a standard product of quality, safety and effectiveness for the device or liquid. The United States Preventive Services Task Force concluded there is insufficient evidence to recommend e-cigarette use to help quit smoking.

E-cigarettes are not intended for youth, young adults, pregnant women or non-tobacco users. Yet, according to the Centers for Disease Control and Prevention, e-cigarettes are the most commonly used tobacco product among U.S. youth, and e-cigarette use is strongly associated with the use of other tobacco products.

Major vaping concerns include the lack of regulation on the ingredients contained in the liquid—nicotine and non-nicotine ingredients and the long-term health consequences of inhaling the substances deep into the lungs, such as potential respiratory complications, impaired brain development and potential death.

Tips For Talking with Teens About E-Cigarettes 1. Know the facts. Visit e-cigarettes.surgeongeneral.gov for 1. credible information.

2. Be patient and ready to listen. Don’t criticize.

2.

3. Encourage an open dialogue to avoid lecturing. Have a more 3. natural discussion to increase the likelihood that he or she will listen.

4.

4.

Find the right moment. You can find opportunities in your daily life, such as someone using an e-cigarette in person or in a video, driving or walking past an e-cigarette shop or seeing an advertisement in a store, magazine or on the internet.

5. Don’t Rush It. It’s OK for the conversation to take place slowly 5. over time.

6.

6.

Ask for support. Include his or her personal doctor in on the conversation at an upcoming visit or suggest your teen talk with another adult who they trust and respect, like a relative, teacher, faith leader, coach or counselor, who can reinforce the same message.

How to Answer Common Questions

Q: Why don’t you want me to use e-cigarettes? What’s the big deal about nicotine?

A: Research shows they contain chemical ingredients that are addictive and can harm different parts of the body, like your lungs, brain and heart.

A: Your brain continues to develop until the age of 25. Using tobacco can change your brain and increase your risk of addiction.

It also can harm your ability to learn new things, your memory and concentration. I don’t want that for you.

A: I don’t say this to scare you. I just want you to know the facts, because nothing is more important to me than your health and safety.

Q: You used tobacco, so why shouldn’t I? A: If I could re-live my life, I never would have tried smoking. I learned that people who smoke cigarettes are much more likely to develop, and die from, certain diseases than people who don’t smoke. That was scary, so I quit.

A: Quitting was very hard, and I don’t want you to go through that.

The best thing is to avoid it altogether.

If you’re interested in quitting smoking or vaping, reach out to your personal doctor to discuss additional resources and options. There are FDA-approved alternatives available, such as nicotine replacement therapy products. You can also reach out to Network Health for more information on our health coaching program for tobacco cessation, which is offered to all members over the phone at no additional cost.

Health coaches can be reached at 866-709-0019 (TTY 800-947-3529) Monday-Friday, from 8 a.m. to 5 p.m.

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WHERE SHOULD YOU GO –

EMERGENCY ROOM?

URGENT CARE?

or

I

f you or a loved one are hurt or ill, panic and confusion can make it difficult to know what to do. If you feel you’re experiencing a medical emergency, it’s important to get to the nearest emergency room or call 911.

Sometimes you might not be sure if your condition is considered an emergency. If it’s not, you can get the necessary care through your personal doctor, a virtual visit or an urgent care walk-in clinic. Two questions can help you determine which type of care is right for you.

What’s the difference between emergency care, urgent care and virtual visits?

An emergency is an illness, injury, symptom or condition so serious, that a reasonable person would seek care right away to avoid serious harm. You typically receive emergency care at the emergency room.

VIRTUAL VISIT? or

Don’t forget to ask questions Anytime you visit the emergency room, a walk-in clinic or see your personal doctor, don’t be afraid to ask questions. Asking questions about your care is the best thing you can do to ensure your safety. There’s no such thing as a dumb question, especially when it comes to your health.

If something doesn’t seem right or make sense, ask about it.

Your coverage for each of these services varies depending on your plan. Visit your member portal at login.networkhealth.com, click My Benefits, then Benefits Overview. You can call the customer service department at the number on the back of your member ID card if you have questions.

Whichever form of care you choose, make sure to share information about the visit with your personal doctor.

Urgent care is for an unexpected injury or illness that is not life threatening, but still needs attention quickly so it doesn’t develop into a serious problem. You may get urgent care at your personal doctor’s office, a walk-in clinic or an urgent care facility.

Another option for care is a virtual visit with MDLIVE®. A virtual visit is a convenient way to get care through your computer, smartphone or tablet. Most Network Health plans offer virtual visits as an alternative to urgent care visits for non-emergency medical conditions. For more information, see the back cover of this Balance issue.

What if I’m not sure if it’s an emergency?

Being prepared and knowing what to do before an emergency can help you make the right decision quickly. For help determining if your situation is an emergency, you can contact your personal doctor. For a list of provider nurse lines, go to networkhealth.com and under the Health and Wellness tab, select Getting Care Quickly.

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Need a Health Coach? t Network Health, we care about your well-being and we are here to support your efforts to maintain or improve your health. Health concerns can be challenging for you and your family and sometimes a little support can make a big difference.

Your Network Health plan includes access to over-the-phone health coaching at no additional cost to you. Our health coaches specialize in motivation and encouragement to help you meet your personal health goals. You will speak one-on-one with a coach to identify and overcome health obstacles and improve lifestyle habits.

For more information about this program, visit networkhealth.com and click the Health and Wellness tab. From the dropdown, select Member Wellness. To receive over-the-phone support and guidance from a health coach, call 866-709-0019 (TTY 800-947-3529) MondayFriday, from 8 a.m. to 5 p.m.

Common topics for conversation include the following.

Nutrition A healthy diet is the best foundation for health. Aim to consume five to seven total daily servings of fruits and vegetables to provide your body with disease-fighting antioxidants and adequate fiber for digestive health and blood sugar stability.

Weight Management Body Mass Index (BMI) assesses your weight in relation to your height. An ideal BMI translates into lower health risks.

Tobacco Use Smoking is one of the leading causes of preventable death in the United States. Quitting smoking lowers your risk of lung and heart diseases and various cancers. The use of e-cigarettes and vaping is skyrocketing, and the health risks are concerning.

Blood Pressure Maintaining optimal blood pressure helps prevent serious cardiovascular conditions. Improve your blood pressure by consuming a healthy diet that is low in sodium, exercising regularly and managing stress levels.

Blood Cholesterol Maintaining adequate cholesterol values helps reduce heart attack and stroke risks. Annual cholesterol testing helps identify if your health risk has changed. A total cholesterol of 200 or below is recommended. Consuming a diet rich in fiber can help lower your cholesterol.

Blood Sugar Elevated blood sugar can lead to diabetes. Diabetes raises your risks for heart disease, vision loss and kidney failure.

To help decrease your blood sugar levels, make healthy choices with your diet, exercise and manage your weight.

Sleep The average adult needs seven to nine hours of sleep per night. Sleep deprivation increases your risk of obesity, high blood pressure, Type 2 diabetes, anxiety and depression.

Alcohol Consumption Moderate alcohol consumption is up to one drink per day for women and two drinks per day for men. Elevated alcohol intake can increase your risk for some cancers. Binge drinking is five or more drinks for men and four or more drinks for women in one sitting.

Additional wellness programs offered by our health coaches at no cost to you include the following.

Prediabetes Health Coaching If you have recently been diagnosed with prediabetes or elevated glucose and have not been diagnosed with Type 2 diabetes, you qualify to receive one-on-one support over the phone with a health coach.

Tobacco Cessation Health Coaching Are you looking for another way to quit using tobacco or vaping? Have you been recently prescribed Chantix and need additional one-on-one support? You qualify to receive over-thephone support with a health coach.

Looking for healthy recipe videos, wellness tips, challenges and more? Join our Facebook Group – My Health and Wellness Network.

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By: Sam Clark, Senior Wellness Coordinator at Network Health

My Health and Wellness Network

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Is It More Than the

Wintertime Blues?

By: Mary Zamost, RN, Quality Health Integration Coordinator

C

older weather, spending more time indoors and holiday stress can bring undesired challenges when it comes to maintaining good mental health. It’s important to recognize and address symptoms to protect all aspects of your health and avoid long-term mental health conditions.

What’s Seasonal Affective Disorder?

More people report feeling depressed during the winter months. For many this is a normal response to less sunlight, but for others it can be a form of depression called seasonal affective disorder (SAD).

Although SAD can occur in warmer months, it is more often linked to winter time with people seeing full improvement in the spring and summer. Diagnosis of SAD requires symptoms of major depression occurring during a specific season for at least two years.

Symptoms may include and are not limited to the following.

Having low energy Difficulty sleeping or over-sleeping Overeating Weight gain Difficulty concentrating Isolating yourself from friends and family Thoughts of death or suicide

SAD occurs more often in women than in men, and more frequently in people who live in northern climates. Younger adults and those with their own history or family history of depression are at higher risk of developing SAD. The cause of SAD is unknown, but it may be linked to an increased production of the hormone melatonin or the decreased production of Vitamin D—both of which are affected by the decreased amount of sunlight during the shorter days of winter.

Recommended treatments include one or more of the following.

Medication Light therapy Psychotherapy Vitamin D

SAD is a serious mental health problem that should not be selfdiagnosed or self-treated. Speak with your personal doctor if you struggle with the changing seasons, experience the symptoms mentioned above, or have difficulty functioning or interacting with others during the winter months. By partnering with your doctor, you can find the solution that is right for you.

Sources: https://www.nami.org/Press-Media/Press-Releases/2014/Mental-health-and-the-holiday-blues https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml http://www.apa.org/news/press/releases/2013/02/seasonal-disorder.aspx

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At Network Health, we know it can be hard to understand health care language and what it means for you. Below are terms or phrases you may have heard, seen in the news or in your personal doctor’s office, with an easy-tounderstand explanation.

Jargon Decoder Population Health – Population health looks at health

concerns and addresses the way resources are used to overcome the problems that drive poor health conditions in the population. It focuses on you, the individual, as a whole rather than concentrating on a single disease.

Physical Determinants of Health – Environmental influences affecting your health. This includes natural environment, physical environment, exposure to hazards, physical barriers, lighting, trees and parks.

Social Determinants of Health – Economic or social

conditions influencing you and affecting your health. Economic and social conditions include availability of resources to meet daily needs, exposure to crime, transportation options, availability of community-based resources, safe housing and access to and quality of education opportunities.

Care Coordination – A patient-centered approach occurring when two or more providers organize patient care activities to ensure you receive appropriate health care services.

Clinical Integration – Patient care coordination including all conditions, providers and settings involved in your care. This is done to achieve care that is safe, timely, effective, efficient, equitable and patient-focused.

Patient-Centered Care – Health care and social services reflecting on your unique preferences, values and needs.

These services are identified and agreed upon with a provider.

Medical Home – An approach to providing primary care

medical practice organized to produce higher quality care and improved cost efficiency.

Preventive Care – Routine health care including screenings, check-ups and patient counseling to prevent illness, disease or other health problems.

Health Risk Assessment (HRA) – An annual health questionnaire that helps identify risk factors and determine if you would benefit from programs that promote health and wellness, prevention and/or disease management.

Online Visits – Online visits, also referred to as virtual visits,

video visits or e-health visits, use interactive secure audio and video telecommunications systems that permit real-time communication between a patient, who is not physically in a facility, clinic or hospital, and a provider who can report evaluation and management services.

Online visits allow providers to diagnose symptoms, prescribe medication and send prescriptions for non-emergency medical conditions. Network Health has partnered with MDLIVE® to provide online visit care. MDLIVE offers services 24 hours a day, seven days a week, 365 days a year.

Telemedicine – Telemedicine is a subset of telehealth that refers to providing clinical health care services and education remotely, using telecommunications technology. Telemedicine occurs when the billing provider offers care from a remote site other than the facility, clinic or hospital where the patient is physically located. This type of office visit is frequently used for follow-up visits, management of chronic conditions, medication management, specialist consultation and other clinical services that can be provided remotely by a provider via secure audio and video connections.

including patients, clinicians, medical staff and families. It is a

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New $25 Insulin Program

A

t Network Health, our mission is to create healthy and strong Wisconsin communities. To do this, we increase your medication accessibility and affordability. Prices for insulin—which is used to treated diabetes—have been skyrocketing for the past few years and studies show that one in four patients report cost-related insulin underuse.

To increase access to life-saving insulin, Network Health is introducing the $25 insulin Patient Assurance Program beginning January 1, 2020.

This program provides less expensive insulin options for our members who get insurance through an employer or who purchase insurance on their own.* This change is possible because in 2020, the Network Health employer group and individual and family plan drug lists have insulin listed as a preventive drug, which brings preferred brand (Tier 3 for individual and family plans and Tier 2 for commercial plans) insulin copayments down to $25 for a 30-day supply or $75 for a 3-month supply at in-network retail pharmacies or through Express Scripts, Inc.® mail order. This allows eligible members—even those on HSA-qualified plans—to access the $25 insulin benefit before they met their deductible.

Visit networkhealth.com/look-up-medications to search for covered drugs and view our 2020 drug lists.

*Not available for Medicare plans, State of Wisconsin employees/members, some self-insured plans, transitional, grandmothered or grandfathered plans .

Are You Using Antibiotics Properly?

By: Mallory Mueller, Manager of Quality Health Integration, Clinical

Antibiotics are powerful medications that treat many common and more serious infections—they save lives when used properly. Depending on the specific antibiotic, it is formulated to either stop bacteria from reproducing or destroy it altogether. Antibiotic resistance occurs when bacteria develop the ability to defeat the drugs designed to kill them. Overtreatment with antibiotics has been identified as the number one factor leading to antibiotic resistance worldwide.

According to the Centers for Disease Control and Prevention, in the United States, antibiotic-resistant infections affect more than 2.8 million people each year, and at least 35,000 people die as a direct result of these infections.

Approximately 30 percent of antibiotic prescriptions in outpatient settings, such as a doctor’s office or urgent care clinic, are either unnecessary or not the most effective treatment. Everyone involved in health care—including the patient—plays a critical role in improving antibiotic use and preventing infections.

You can decrease your chance of developing antibiotic resistance by increasing your awareness of the proper use of the drugs. These are the top things you should know about antibiotic use.

1. Antibiotics do save lives. When antibiotics are needed, the benefits usually outweigh the risk of side effects or antibiotic resistance.

2. Antibiotics aren’t always the answer. Taking antibiotics when they aren’t needed increases your risk for adverse drug reactions and future antibiotic-resistant infections.

3. Antibiotics only treat infections caused by bacteria. Some bacterial infections get better without antibiotics, including many sinus infections and some ear infections.

4. Antibiotics will not make you feel better if you have a virus, such as a cold, bronchitis or a runny nose.

Respiratory viruses usually go away in a week or two without treatment. Ask your personal doctor about the best way to feel better while your body fights a virus.

5. If you need antibiotics, take them exactly as prescribed. Talk with your personal doctor if you have any questions about your antibiotics or if you develop any side effects, especially diarrhea, which could be the sign of something more serious.

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Important Pharmacy Network Updates On January 1, 2020, Network Health transitions to Express Scripts, Inc.® (ESI) as your pharmacy benefits manager (PBM). ESI has provided pharmacy benefits management for Network Health Medicare Advantage members since 2005, saving members money and providing excellent customer service. Starting in 2020, they will provide those same services to our commercial members.*

What does this mean for you?

• Many large retail pharmacies, including Walgreens, Costco, Meijer, Pick ‘n Save, Walmart and Sam’s Club are in-network pharmacies through this change.

• On January 1, 2020, CVS/caremark (including Target) pharmacies are out-of-network.

• You can search the entire updated pharmacy network, both retail and mail order, at networkhealth.com/find-a-pharmacy.

• If you are currently using CVS/caremark for mail order, you can contact ESI as early as January 1, 2020, to establish your mail order services.

• Your 2020 member ID card has been updated to reflect ESI as the PBM. Beginning January 1, 2020, you must use your 2020 ID card when picking up your medications at the pharmacy. It is important to follow these instructions, so your pharmacy uses the most up-to- date plan benefits to process your insurance. This will avoid being overcharged at the pharmacy.

Not available to State of Wisconsin employees/members.

Approaching 65?

Network Health has you covered.*

I

f you or someone you know is turning 65, check out Network Health’s Medicare Advantage Plans. You will receive the same exceptional one-on-one Network Health service you’ve experienced for years, and these plans will cover you into the next stage of your life.

As good as Original Medicare is, it will not cover all your health care expenses. Most people who are eligible for Medicare choose to get their benefits through private health insurance companies to help cover costs.

With Medicare Advantage plans, you can also get coverage for services and procedures that Original Medicare doesn’t cover.

Learn more about Network Health’s Medicare Advantage Plans by calling 866-755-5233 (TTY 800-947-3529) or visit networkhealth.com and select the Medicare Plans tab. *Not available to State of Wisconsin employees/members.

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PRESORT STD US POSTAGE PAID PERMIT 1033 GREEN BAY, WI

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Doctor Visits From the Comfort of Your Home ® With , you can visit with a doctor or counselor 24/7 from your home, office or on-the-go

With Network Health, you have a virtual doctor visit benefit offering you care, anywhere • • Board-certified doctors • Available anytime, day or night • Available anytime, day or night • Consults by mobile app, video or phone • Consults by mobile app, video or phone • Prescriptions can be sent to your nearest if • Prescriptions can be sent topharmacy your nearest medically necessary pharmacy if medically necessary

Treating over 50 routine medical conditions, including these and more

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• And more

NETWORK to 635483 to Download the Text be walked through step-by-step MDLIVE app registration on your phone.

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Copyright © 2019 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. 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://www.MDLIVE.com/terms-of-use/. HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health Insurance Corporation or Network Health Insurance Corporation and Network Health Plan.