Concierge for Southeast Network Health Medicare Members

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

A PUBLICATION OF

FA L L 2 01 8

Impacting Lives, One Prescription at a Time Read about how Ellen saved $77 per month by discussing her medications with a Network Health pharmacist

PAGE 5

Why Is It Important to Get Your Flu Shot?

PAGE 9

Myth Busters ...

Brand Name Drugs vs. Generic Drugs

BACK COVER

Your New Member Portal

SPECIAL PULLOUT SECTION 2019 MEDICARE PLAN CHOICES AND BENEFITS

Exclusive Reduced Rates for Network Health Medicare Advantage Plan Members For ticket information, visit networkhealth.com/offers Fox Cities Performing Arts Center - Appleton, Wisconsin FIDDLER ON THE ROOF – Dec. 2 at 1 p.m.

Tickets on sale now. Offer expires Nov. 12, 2018. Subject to availability.

Marcus Center - Milwaukee, Wisconsin HOW THE GRINCH STOLE CHRISTMAS – Nov. 23 at 2 p.m. and Nov. 24 at 5 p.m.

Priority Seating - Tickets on sale now. Offer expires Nov. 18, 2018. Subject to availability.

THE PHANTOM OF THE OPERA, ANDREW LLOYD WEBBER’S NORTH AMERICAN TOUR – March 7 at 2 p.m. and March 17 at 6:30 p.m.

Priority Seating – Tickets on sale now. Offer expires March 1, 2019. Subject to availability.

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4 Partnership Spotlight 4 Join Our Member Advisory Council 5 Why Is It Important to Get Your Flu Shot?

6 Three Best Exercises for Balance and Stability 7 How Prior Authorizations Impact Your Care 8 The Silent Disease—Osteoporosis

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3 Letter from the President and CEO 4 An Interactive Experience

9 Myth Busters ...

Brand Name Drugs vs. Generic Drugs FEATURE 10 Impacting Lives, One Prescription at a Time 13 What Is Medication Therapy Management?

15 Provider Profile – Dr. Arvind Ahuja, Froedtert South 15 Breaking Down Obstacles to Care 16 The Service You Deserve 18 Tips to Avoid Medicare Fraud 18 Know Your Member Rights and Responsibilities 19 Evaluating New Technologies SPECIAL PULLOUT SECTION 2019 MEDICARE PLAN CHOICES AND BENEFITS BACK COVER You Gave Us Feedback. We Listened.

14 Take Control of Your Health with Our Help

Y0108_1550-02-0918_C EDITORIAL STAFF President and CEO Coreen Dicus-Johnson Chief Administrative Officer Penny Ransom Marketing Coordinator Romi Norton

Lead Designer Debra Sutton

ASK NETWORK HEALTH If you have questions about anything you read in this issue of Concierge, call customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, 8 a.m. to 8 p.m. You can also learn more at networkhealth.com.

Concierge is a biannual publication of Network Health. The health information contained in Concierge is meant to supplement, not replace, the advice of health care professionals. © 2018 Network Health Insurance Corporation. No portion of this newsletter may be reproduced without written permission from Network Health Insurance Corporation.

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 800-378-5234 (TTY 800-947-3529). 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 800-378-5234 (TTY 800-947-3529). 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 800-378-5234 (TTY 800-947-3529).

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life. health. wellness.

Letter from the President and CEO

T

hank you for being a Network Health Medicare member. To ensure you are using the full array of benefits Network Health offers, this edition of Concierge is filled with essential information to guide you in your wellness experience.

One of the key features impacting many of you is our pharmacy department and the medication therapy management program. We have a tremendous team of clinical pharmacists here to help you. They can work closely with your personal doctor and your local pharmacist to make sure you are taking the right medications to benefit your personal health and your pocketbook.

Some members automatically qualify for a medication review. For other members, the pharmacy team can provide personalized assistance to you as well—all you need to do is ask. Sometimes taking the right medications can make the difference in experiencing fewer side effects, taking less medication overall and better yet—saving money. I encourage you to take advantage of this service offered by Network Health.

Best regards,

Coreen Dicus-Johnson President and Chief Executive Officer

See page 10 for a member’s story about her savings. networkhealth.com

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life. health. wellness.

An Interactive Experience Why are there Emmi icons featured throughout this issue of Concierge?

By visiting the links provided, or viewing Concierge online, you can view interactive videos on a variety of health topics. Each icon takes you to free, animated, online programs provided by Emmi®.

Watch them on your computer, smartphone or tablet as many times as you like.

PARTNERSHIP SPOTLIGHT N

etwork Health assures the highest standards of quality, service and affordability for you. To ensure you receive the best and most appropriate care possible at the most appropriate time, we partner with eviCore HealthCare and other support providers with expert consultation and tools.

Here are some services that require prior authorization through eviCore HealthCare.

Interventional pain management n Large joint procedures of the hip, knee and shoulder n Spinal procedures n Radiation oncology therapy services n Medical oncology services n Molecular genetic lab testing n All ambulatory cardiac diagnostics including diagnostic cardiac catheterizations, nuclear cardiology scans, stress echocardiograms, transesophageal echocardiograms n

If you receive care at an in-network provider, there’s nothing you need to do to ensure authorization requirements are met. Your doctor will request the authorization for your care. See page seven for more information on prior authorizations.

Join Our Member Advisory Council

We appreciate your experience as a Medicare member and value your input. We invite you to serve on our member advisory council. Our council helps shape the decisions of Network Health, so we continue to offer the quality service and plans you need and want. For more information contact customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m.

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Why Is It Important to Get Your Flu Shot?

By Michele Eggers, coordinator quality health, with Network Health

People age 65 and older are at greater risk of serious complications from the flu due to weakening immune systems.

The Centers for Disease Control and Prevention estimates as many as 85 percent of flu-related deaths and 70 percent of flu-related hospitalizations occur in people age 65 or older.

Most people who get the flu will recover within two weeks, but others may develop serious complications, including the following.

Pneumonia Respiratory failure Kidney failure

Inflammation of the heart, brain or muscle tissue Worsening of chronic medical problems such as asthma and heart disease

The best way to protect yourself is to get an annual flu shot. Each year, flu vaccines are developed to protect against current viruses.

It takes approximately two weeks to build up immunity, which then lasts about 12 months. Get your flu shot as early as possible to ensure you’re protected from the beginning through the end of flu season.

Although there are vaccines developed for high-risk individuals, most people should not delay vaccination while waiting for a specific vaccine to become available unless recommended by your doctor or pharmacist.

People age 65 and olde r should not get the following.

Nasal spray flu vaccin e (only approved for people 2-49 year s old) Intradermal flu shot (only approved for people 18-64 years old) Jet injector flu vaccin e (only approved for people 18-64 ye ars old)

Protect yourself this season with these additional precautions.

Cover coughs, wash hands often and avoid people who are sick.

Seek medical advice if you develop flu-like symptoms (such as fever, cough, sore throat, body aches, chills or fatigue). A medical evaluation or treatment with antiviral drugs may be necessary for those at higher risk of complications. Antivirals are most effective if started within two days of developing illness.

Stay up-to-date with pneumonia vaccinations.

Getting a flu shot is easier than suffering through flu symptoms and can help you stay healthy year-round.

Visit www.goemmi.com/NHP-FLU for free, interactive programs on the flu vaccine. networkhealth.com

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life. health. wellness.

3

Best Exercises for Balance and Stability

By Aleisha K. Fetters with SilverSneakers®

W

hen we’re young, we take staying upright for granted. We don’t really worry about falling—it might not even cross our minds.

Over the years, things change. The body’s systems that detect gravity, identify exact body positioning at any moment, determine what you need to do to stay upright and promote balance and stability become less effective, says Caroline DeGroot, M.P.T., a physical therapist at Athletico.

It’s easy to see why falls are the number one cause of injuries and death among older Americans. In fact, according to a report from the Centers for Disease Control and Prevention (CDC), an older adult falls every second of each day in the United States.

If you’ve fallen, tell your personal doctor. Half of older adults who fall don’t tell their doctor—which means injuries can go untreated and a balance problem could get worse. Follow your personal doctor’s instructions for any treatment or physical therapy and ask how you can exercise safely.

It’s never too early to start thinking about improving your balance and preventing falls. Below, DeGroot shares her favorite exercises for better stability. Perform these bodyweight moves as often as possible—when you’re standing at the kitchen counter or waiting in line while running errands.

With each exercise, hold onto the wall or a sturdy piece of furniture for balance.

As you get stronger, you can try without holding onto anything.

1. Foot Taps Stand tall with your feet hip-width apart in front of a step (the bottom step of a staircase will work) or low piece of furniture. From here, slowly raise one foot to tap the step in front of you, and then slowly return it to the floor. Perform 15 to 20 taps, then repeat on the opposite leg.

2. Head Rotations Stand tall with your feet hip-width apart. From here, slowly move your head from side to side then up and down while keeping your body as still as possible.

Do this for 30 seconds and repeat. If you get dizzy, pause and move your head more slowly. If you’re still dizzy, stop.

3. Standing Marches Stand tall with your feet hip-width apart. From here, lift one knee until your thigh is parallel to the floor (or as close to parallel as you can get) while keeping your torso straight and avoiding any leaning. Pause, then slowly return your foot to the floor. Perform 20 marches, alternating legs with each march.

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What else can you do?

Tell your personal doctor if you have fallen recently, feel unsteady on your feet or feel lightheaded or dizzy often.

Tell your personal doctor about all the medications you take, including prescription drugs, over-the-counter medications and supplements. Your doctor will check if any medications increase your risk of falling.

As always, do not stop or change medications unless instructed by your doctor.

Work with your personal doctor to manage any chronic conditions like diabetes or arthritis. The healthier you are overall, the lower your risk of falling.

Get your eyes checked once a year. Vision problems can increase your risk of falling.

Eat bone-strengthening foods with plenty of calcium and vitamin D. Practice balance exercises regularly. If you prefer group exercise, check out SilverSneakers Stability or tai chi classes.

Keep your floors free of clutter. Secure or remove loose rugs and make sure there is plenty of light. Don’t be afraid to ask family or friends for help with these tasks.

To find SilverSneakers classes near you, visit SilverSneakers.com today.

How Prior Authorizations Impact Your Care

H

ave you ever been asked to submit a prior authorization before care is covered by your health insurance? Did you wonder why? It’s a common question, and we’re here to give you the answer.

What is a prior authorization? Certain prescriptions,

procedures and equipment require approval from a Medicare plan before they are filled or completed to be sure that they are covered by the plan.

Why is this important to you? Fraud, waste and abuse can

exist in the medical profession and prior authorizations help to reduce those issues and create a much better experience for you while controlling overall health care costs.

How is the review conducted? Medical experts review

records and documentation to decide the best course of action.

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Example. You’re asked to submit a prior authorization for rotator cuff surgery. The medical experts at the insurance company review the records and x-rays and deny the surgery. Instead, they recommend you have physical therapy because surgery may not be necessary. Although upset with the insurance company at first, you participate in physical therapy and never need to have the surgery.

While surgery may have been successful, the physical therapy was much easier reducing recovery time and overall costs.

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life. health. wellness.

The Silent Disease—Osteoporosis

By Carol Hirn, RN/BSN with Network Health

O

steoporosis may affect more than half the population in the United States at some time in their lives. You may hear it referred to as “brittle bones” or “weak bones.” Osteoporosis is also often called the “silent disease” because people usually have no symptoms and may not know they have osteoporosis. The weakening of their bones, however, significantly increases their risk for an injury or fall causing a broken bone.

Both men and women can have osteoporosis, but here are some factors that put you at higher risk.

GENDER

AGE

It’s more common in women.

BODY SIZE

The older you are, the Small, thin women higher your risk. are at greater risk.

ETHNICITY

FAMILY HISTORY

White and Asian women are at highest risk.

Osteoporosis tends to run in families.

A healthy lifestyle can help decrease your risk

Eat a diet rich in calcium and vitamin D. Low fat milk, yogurt and cheese as well as foods with added calcium—orange juice, cereals and breads—are all good sources. Ask your personal doctor if a Vitamin D or calcium supplement is right for you.

Exercise, especially weight bearing exercise such as walking, hiking, dancing and lifting weights, can all help increase bone strength.

Limit your alcohol intake.

Don’t smoke, or take steps to quit smoking.

To help minimize the effects of falls or fractures, your doctor may recommend a bone density test or medications to help protect your bone strength.

WHAT’S THAT? A BONE DENSITY TEST measures the amount of bone mineral in your bone tissue, determining the density of bones and the chances of the bone being broken. A bone density test is recommended for most women age 65 or older, or younger for those at risk and/or those who have had a recent fracture.

Visit www.goemmi.com/NHP-BONE for more information on osteoporosis.

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h t My rs … te s u B

d

an me a n nd ay. t bra xist tod u o e ab ths ations y m ic y Man ric med e gen

Brand Name Drugs

vs.

Generic

Drugs

By Anna Peterson Sanders and Gary Melis, pharmacists with Network Health

Myths

Brand name is best.

Generics are less effective.

Brands cost more, but are worth it because they work better.

Generics hit the market with little oversight.

Brands are safer.

T

he truth is, the U.S. Food and Drug Administration (FDA) has a very extensive process that generic manufacturers must undergo before approval. Here’s a summary of the FDA’s process.

Generic versions must have the same active ingredients, effectiveness, quality, safety, strength and benefits as the brand version.

• The active ingredient is the chemical portion of the medication that allows it to do what it’s supposed to.

• Inactive ingredients are also present in medications and do not provide benefit or harm. They are used to create the medication to help in different ways including binding, dissolving, stability and taste. The FDA requires that inactive ingredients are determined to be safe.

The manufacturer must be able to make the medication correctly and consistently, ensuring it doesn’t break down over time and that the container used to sell the medication is appropriate.

In addition, a generic medication cannot be approved until the patent on the brand has expired.

• Patents allow exclusive marketing rights for a certain period of time, giving manufacturers financial incentive to invest in drug development. Without competition, this gives companies an opportunity to price their drug much higher than will later be seen with its generic counterparts, helping them recoup drug development costs.

• Generics are less expensive because they do not need to repeat the studies that the brand must undergo.

Additionally, multiple companies often begin making the generic version, providing market competition.

This results in a reduction in cost, which is usually about 85 percent less than the brand name.

So, while brand name medications cost more, it doesn’t mean they are better than generics. Just as brand name medications undergo an FDA review, generics also go through an FDA review process to be deemed equivalent to the brand version. Be assured that generics are just as safe and effective as brands, but have the added advantage of being much kinder to your wallet.

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COVER STORY

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IMPACTING LIVES One Prescription at a Time

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By Romi Norto

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COVER STORY

H

ave you ever been at the pharmacy checkout counter and wondered how the total price got so high?

Prescription medications can be expensive, but they are a critical part of maintaining or improving your health. You know they must be taken as prescribed to stay healthy.

Every month, you dutifully fill your prescriptions, but in the back of your mind, you think about the growing expense. You may even discuss other available options with your personal doctor and occasionally you may get some financial relief.

We recently spoke with Network Health Medicare Advantage members Ellen and Art S. who had a similar experience. Ellen had been prescribed Symbicort® which resulted in an out-of-pocket expense of $110 per month for one prescription. At the time, she wasn’t sure that any other options were available. That’s what her personal doctor had prescribed and that’s what she was going to take.

Fortunately for Ellen, she participates in the Network Health Breathe at Ease program which connects her with a respiratory therapist. She receives a monthly phone call from respiratory therapist Robyn West to see how she is doing. In fact, it was Robyn who recommended Ellen reach out to Network Health Pharmacist Gary Melis to determine if there were any options available for a lowercost inhaler.

“Robyn thought that something could be done about the prescription, that there might be another option that would be comparable and less costly. I think it’s great that she was advocating for me, I really appreciate Robyn’s help. She’s very encouraging and listens. I like that somebody is keeping track of how I am feeling,” Ellen said.

She continued, “I had a phone call with Gary to talk about the options. It didn’t take long at all. He recommended fluticasone/salmeterol which is like a powder inhaler. He said it would be less expensive monthly and provide the same relief.” Ellen ended up saving $77 per month.

Most members may not realize that the Network Health pharmacists are available to offer this type of assistance.

The pharmacists can provide individual medication review options like Ellen’s experience. Network Health also offers a program called Medication Therapy Management (MTM) which takes a deeper dive and reviews all the medications a member takes, including over-the-counter items and vitamins.

When Ellen was asked if she knew about the pharmacy programs available at Network Health before Robyn mentioned it, she said, “Someone called me at one time. I thought, I don’t want my insurance interfering with what I was doing. I didn’t want them to tell me what I could do and couldn’t do. I did not understand at the time that they would be there to help me with whatever I needed.”

“Gary was very helpful. He got things straightened out and recommended this new prescription. He said if I was willing to try it, that would be a good thing.”

When asked her opinion about the Network Health pharmacy program, Ellen said, “If you have a chance to work with them, go ahead and do it. They may be able to help you save money and get yourself organized.”

Ellen and Art look forward to doing fun things with the additional monthly savings. “We enjoy special Friday night dinners out with friends.”

Meet Gary Melis, Registered Pharmacist Gary Melis is a clinical pharmacist who has been with Network Health for seven years. Gary is one of the three pharmacists that manage the Medication Therapy Management (MTM) program.

He reaches out to Network Health members directly to assist with medication reviews. With retail pharmacy and long-term care experience, Gary brings a wealth of knowledge to our members. He also volunteered as a pharmacy instructor at Mosaic Family Health in Appleton.

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If you have a chance to work with them, go ahead and do it. They may be able to help you save money and get yourself organized.

Ellen S., Network Health Medicare member

What Is Medication Therapy Management?

Members that meet eligibility requirements are automatically enrolled in the MTM program and will receive the following, at no additional cost.

An introductory letter explaining how to get started.

An offer to participate in an annual comprehensive medication review. This review will ensure you get the best results from your medicines from the comfort of your home.

A follow-up letter that outlines the review and suggests next steps. This is a great tool to share with your personal doctor and other health care providers.

To meet eligibility requirements, members must meet the following the criteria.

1.

Have at least three of the following long-term (chronic) medical conditions: asthma, chronic heart failure, chronic obstructive pulmonary disease (COPD), depression, diabetes, end stage renal disease, high blood fat levels, high blood pressure or osteoporosis.

2.

3.

Take seven or more daily medicines covered by Medicare Part D.

Part D covered medications cost more than the CMS specified annual cost threshold.

For 2019, that amount is $3,820.

If you don’t meet the eligibility requirements but are still interested in reviewing your medications, call a health care concierge at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m. to schedule time to speak with a pharmacist.

As a Network Health Medicare member, this service is available at no cost to you.

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Take Control of Your Health

with Our Help

D

id you know Network Health offers member wellness, condition management and care management services at no cost to you?

Whether you’re dealing with an unexpected health issue, a complex diagnosis, a chronic disease or just need a little help maintaining your health, care management services can help. Managing your health conditions can increase your sense of well-being and put you in control of your health.

Our member wellness coordinators work with you to meet your goals with the following.

Nutrition Weight loss or management Physical activity Stress management Blood pressure Blood cholesterol Blood sugar Sleep concerns Quitting tobacco For our members with diabetes, heart disease, heart failure, chronic obstructive pulmonary disease (COPD) or depression, our condition management team can provide educational resources specific to your diagnosis.

Care management begins with a one-on-one conversation between you and one of our care managers. If you choose to participate, they will work with you to help you manage your health conditions and meet your health goals.

After learning more about you and your health concerns, your care manager can assist you with the following.

Answering any questions you may have Reviewing your medications and treatment plans Informing you about the signs that your health condition is worsening and when to act, including when you should contact your personal doctor Working with your health care providers to ensure they are aware of changes in your health Ensuring you and/or caregivers feel included in your health care decisions Helping set health care goals to maintain or improve your health Helping you with coordination of care with providers and community services

To benefit from member wellness or care management support, or find out more about our programs, call 866-709-0019 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 5 p.m. You may leave a message 24 hours a day, seven days a week. Or get more information on our programs at networkhealth.com, select Medicare Plans and select Wellness Programs. Participation is optional and you may opt out of care management at any time by calling the health care concierge team at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m.

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Provider Profile –

Dr. Arvind Ahuja, Froedtert South

P

atrick Berger never thought much about brain health until his mother died from a ruptured brain aneurysm in 2002. Her surgeon advised Patrick to get himself checked due to the strong hereditary link of the condition. As it turns out, that aneurysm screening saved Patrick’s life; it showed that he had a 4-millimeter aneurysm.

I really believe that if I didn’t find out, by this time, I would not be here, Berger said.

Dr. Arvind Ahuja, a neurosurgeon affiliated with Froedtert South, performed a craniotomy to eliminate Patrick’s aneurysm. An aneurysm is thinning of the wall of a blood vessel, which may result in the ballooning of that area. If it ruptures, the person typically feels the worst headache of his or her life.

“One-third die immediately; one-third die in the hospital; one-third survive,” said Ahuja.

Dr. Arvind Ahuja

Approximately one in every 50 people will develop an aneurysm at some point in life.

“They may not need treatment for them, but they may have them,” Ahuja said.

“Smoking and high blood pressure are controllable risk factors,” Ahuja added.

If you have a “first-degree relative” who has had an aneurysm your chances of developing one are double; with two family members, it’s quadruple.

Dr. Ahuja is the only neurosurgeon in the Kenosha area experienced to perform both aneurysm repair procedures (clipping and coiling).

“I was off work for eight weeks, then went back to work and everything was fine,” Patrick said. “I literally had no problems at all.”

WHAT’S THAT? A FIRST-DEGREE RELATIVE is considered a parent, sibling or child.

Breaking Down Obstacles to Care

Treatment plans are only helpful if you follow them. What if your doctor’s orders conflict with your religious beliefs or create tension with your cultural practices?

What if you can’t afford the treatment? If you find yourself facing decisions between following your beliefs or your doctor’s instructions or you are struggling to pay for treatment, Network Health can help.

Network Health’s care management team helps people overcome barriers to treatment requirements every day, including the following.

Beliefs and concerns about your condition and treatment Access, transportation and financial barriers to obtaining treatment Cultural, religious and ethnic beliefs that conflict with treatment

Call 866-709-0019 (TTY 800-947-3529) to speak with a nurse who can help ensure your treatment plan fits your life. networkhealth.com

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life. health. wellness.

The

Service YOU

DESERVE

t Network Health, we make every effort to ensure you’re receiving the service you need and deserve. If concerns arise, 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 file an appeal?

You have the right to file an appeal if you do not agree with Network Health’s decisions about your health care.

You can submit an appeal in writing within 60 calendar days from the date you receive the claim denial. Your written appeal should include your full name, member ID and information about what you are appealing. 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 an appeal include the following.

Network Health will not approve care it should cover.

Network Health is stopping care you still need.

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

n n n

Who may file an appeal?

You or someone you name to act for you (called your representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor or someone else to act for you. To name your representative, visit networkhealth.com, select Medicare Plans, select 16 | C oncierge

Member Resources and select the Appointment of Representative form. Simply complete this form and send it as outlined in the Contact Information section.

What happens after I file an appeal?

If you appeal, we will review our decision. If payment for any of your claims is still denied after our review, we will automatically forward your Part C appeal request to the Medicare contractor (MAXIMUS Federal Services) for an independent review. This process is provided by Medicare for a new and impartial review of your case outside of your Medicare Advantage organization. If you disagree with that decision, you will have further appeal rights and you’ll be notified of those appeal rights if this happens.

How are medication appeals handled?

Medication appeals 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 have a goal of addressing medication appeals within four hours and have been successful over 90 percent of the time. This means better customer service for both physicians and our members. networkhealth.com

When do I file a grievance?

If you’re dissatisfied with the service or quality provided by your plan or doctor, we’re here to work with you through any issues. You have the right to file a grievance (a formal complaint) about how Network Health, our vendors or contracted providers provided services.

Examples of situations appropriate for a grievance include the following. n n n n

Difficulty getting through on the phone Concerns about the quality of care of services provided Interpersonal aspects of care (for example, rudeness of a provider or staff) Failure to respect your rights

Contact Information Appeals and Appointment of Representative Form Call: Health Care Concierge Team at 800-378-5234 (TTY 800-947-3529).

Fax: 920-720-1832 Write: Network Health

Attn: Medicare Advantage Plans P.O. Box 120 Menasha, WI 54952

networkhealth.com

You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event.

See the Contact Information provided.

Grievance

Call: Health Care Concierge Team at

800-378-5234 (TTY 800-947-3529)

Fax: 920-720-1832

Write: Network Health

Attn: Appeals and Grievances

P.O. Box 120

Menasha, WI 54952

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life. health. wellness.

Tips to Avoid Medicare Fraud

M

edicare fraud costs American taxpayers billions of dollars each year and results in higher medical costs for everyone.

Network Health offers some tips to help you avoid Medicare fraud. Follow this guide to keep your information safe.

DO •

•

• •

•

•

Refuse and return medical supplies you didn’t order.

Medicare doesn’t sell or mail supplies. If you receive unordered supplies, you may be the target of fraud.

Let Network Health know the name of the company that sent the supplies.

Keep accurate records of all your health care appointments.

Read your explanation of benefits carefully and make sure all services listed are services you received.

Always watch your credit card and bank statements for any improper billing activity or fraudulent withdrawals.

Monitor your credit report regularly.

DON’T •

•

•

Don’t give your Social Security, Medicare, financial information, Network Health member ID number or credit card information to someone you don’t know. Only give your information to those who have provided you with a medical service.

Don’t trust door-to-door salespeople or telemarketers selling health care services or durable medical equipment, like diabetic supplies or back braces. And, remember—free services do not require you to give out your plan or Medicare number.

Never sign blank insurance claim forms.

What if I’m scammed?

Sometimes people do not report scams because they are ashamed or embarrassed. It is important to know it’s not your fault. If you feel you are the victim of a Medicare scam, we are here to assist you. Call a member of our health care concierge team or send an email to paymentintegrity@networkhealth.com.

You can always call our Values Line to report and discuss activities or occurrences you believe are improper. The hotline is confidential, and you may report concerns anonymously. Your concerns will be investigated and appropriate action will be taken to address the problem.

The Values Line number is 800-707-2198 (TTY 800-947-3529) and can be reached 24 hours a day, seven days a week.

Know Your Member Rights and Responsibilities Did you know you have rights and responsibilities as a Network Health Medicare member? To learn more about how we provide you with service that respects your rights, go to networkhealth.com, select Medicare Plans and select Member Resources. On this page you’ll find Member Rights and Responsibilities. You can also call customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 8 p.m. to request this information.

18 | C oncierge

networkhealth.com

Evaluating New Technologies

Have you ever wondered why new benefits get added to your health plan? Why is something covered this year when it wasn’t covered last year?

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etwork Health evaluates new technology and new applications of existing technologies on a regular basis to ensure our members receive safe and effective treatment and care. We evaluate medical and behavioral health procedures, drugs and devices. We base our decisions on the following.

Food & Drug Administration approval Scientific evidence Opinion of contracted providers Government regulatory agencies Manufacturer information Peer-reviewed articles Risk/benefit analysis Assessments performed by agencies specializing in technology

n n n n n n n n

New technologies are reviewed by our Medical Policy Committee (MPC), which is comprised of a group of participating physicians and Network Health employees. This group makes recommendations for inclusions as a covered benefit.

The following technologies have been reviewed over the past 12 months.

Technology Review

Outcome

3D mammography/a.k.a. breast tomosynthesis

MPC decided this technology is safe and effective; Network Health has removed this technology from our experimental, investigational and unproven review process.

OPTUNE Device (Tumor Treatment Fields therapy TTF)

MPC decided this technology remains experimental, investigational and unproven.

Epifix (skin substitute material)

MPC determined this to be safe and appropriate for diabetic foot ulcers and venous stasis ulcers, when applicable criteria are met. This has been added to our Skin Substitutes Medical policy.

Grafix (skin substitute material)

MPC determined this to be safe and appropriate for diabetic foot ulcers when applicable criteria are met. This has been added to our Skin Substitutes Medical policy.

If you have a question about a technology assessment, contact our care management department at 800-236-0208 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 5 p.m. networkhealth.com

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1570 Midway Pl. Menasha, WI 54952

PRESORT STD US POSTAGE PAID GREEN BAY, WI PERMIT NO. 1033

SE

You Gave Us Feedback.

We Listened.

Based on member testing and feedback, we’ve given our member portal a complete makeover to provide you an improved experience. In it, you’ll find content that’s unique to you. You’ll also find tools, tips and important information to help get the most out of your benefits. Plus, the new portal is mobile responsive, so you can access your plan information 24/7 from any device.

Create your new account today at login.networkhealth.com.

The first time you visit the new portal, you’ll need to create a new account. Whether or not you’ve accessed our old portal, you’ll still need to create a new account.

Once signed in, you can get benefit information, find a doctor, view out-of-pocket expenses, reorder an ID card, access plan materials and more. You’ll also be able to select communication preferences, so you can choose to receive Explanation of Benefits statements by email instead of mail.

Set up your new account now at login.networkhealth.com, so you’ll have easy access to everything you need to manage your plan.

What Else Will You Find?

• Benefits and coverage overview • Out-of-pocket expenses tracker • Claims detail and status • Explanation of benefits statements • Authorization information and status • Mobile access to order an ID card • Plan-related materials and forms • Secure messaging with our local customer service team • Ability to make a premium payment • Wellness tools

Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. NetworkCares is a PPO SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal.

no tic e

ic e es di yo ca u’l a nd re dif l Be Pla fer ne n en the fit ce s

So PP uth Ch O eas o M t

2019

800-983-7587 TTY 800-947-3529 networkhealth.com

My 2019 Medicare PPO Plan Annual Review Agent name_________________________________________________________________________________________ Agent phone number__________________________________________________________________________________

To ensure your current PPO plan continues to fit your needs for 2019, consider the following.

q I take prescription medications.

q A fitness benefit is important to me.

q I work out at a fitness center.

q My out-of-pocket maximum is____________.

If you do, you’ll need a plan that includes drug coverage.

The out-of-pocket maximum is the yearly limit on your costs for medical services. This is one of the most important things to consider. To protect your pocketbook, pay attention to this amount.

q My primary care office visit

copayment is_________________________.

Consider this amount if you visit your doctor often.

q My specialist visit copayment is__________.

Consider this amount if you visit specialists.

q My deductible for medications is__________. q Do you travel?

q I have a chronic condition and should be working out. q I have a heart condition. q I want to improve my health.

If you’ve selected any of the above options, check to see if your plan includes the SilverSneakers® fitness benefit.

q A vision and dental benefit is important to me.

q I get a yearly exam.

If you’ve selected this option, check to see which plans include _ these benefits

Which doctors can I see?

All Network Health Medicare Advantage Plans in this book are PPO plans, which means you can see any doctor who accepts Medicare beneficiaries. bfound on page 16.

Network Health’s Medicare Advantage PPO Plans provide in-network coverage, regardless of which state you visit.

Use the plan comparison to fill in the blanks.

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 800-378-5234 (TTY 800-947-3529). 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 800-378-5234 (TTY (800-947-3529). 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 800-378-5234 (TTY 800-947-3529).

Customer Service 800-378-5234 (TTY 800-947-3529) | Sales Representative 800-983-7587 | networkhealth.com

A Quick Summary

Network Health Medicare Go (PPO) IN-NETWORK

Network Health Medicare Anywhere (PPO) OUT-OF-NETWORK

IN-NETWORK

OUT-OF-NETWORK

Premium

$0 per month (Includes pharmacy)

$25 per month (Includes pharmacy)

Maximum Out-of-Pocket Primary Care Office Visit Specialist Visit

$5,900 per year combined, in- and out-of-network

$4,500 per year combined, in- and out-of-network

$10 copayment

$20 copayment

$5 copayment

$15 copayment

$45 copayment

$55 copayment

$45 copayment

$55 copayment

Urgent Care

$45 copayment

$45 copayment

$45 copayment

$45 copayment

Hospital Stays

Days 1-4 $395/day copayment Days 5 and beyond $0 copayment

Days 1-5 $395/day copayment Days 6 and beyond $0 copayment

Days 1-4 $295/day copayment Days 5 and beyond $0 copayment

Days 1-4 $395 Days 5 and beyond $0 copayment

Emergency Room

$90 copayment

$90 copayment

$90 copayment

$90 copayment

Ambulance

$275 copayment

$275 copayment

$250 copayment

$250 copayment

$395 copayment

$395 copayment

$295 copayment

$395 copayment

$0 copayment

$15 copayment

$0 copayment

$15 copayment

$0 copayment

$15 copayment

$0 copayment

$15 copayment

Low Cost Labs

$0 copayment

$30 copayment

$0 copayment

$25 copayment

Outpatient X-rays

$35 copayment

$45 copayment

$20 copayment

$45 copayment

MRI/CT

$125 copayment

$140 copayment

$125 copayment

$140 copayment

SilverSneakersÂŽ

Included

Included

Included

Included

$10 copayment

$30 reimbursement

$10 copayment

$30 reimbursement

Not included

$30 copayment

Not available

$35 per month

$35 per month

Outpatient Surgery Services Annual Wellness Visit with Lab Tests Preventive Care

NEW BENEFIT Annual Eye Exam Annual Dental Exam and Cleaning Optional Dental Rider

Customer Service 800-378-5234 (TTY 800-947-3529) | Sales Representative 800-983-7587 | networkhealth.com

Our Plan Drug Costs

Network Health Network Health Medicare Go (PPO) Medicare Anywhere (PPO) When your coverage starts, you pay a deductible for tiers 3, 4 and 5 only; and copayments until total drug costs (what you and Network Health pay) reach $3,820.

Drug Deductible

$275 For tiers 3, 4 and 5 only

$250 For tiers 3, 4 and 5 only

$2 for Tier 1 $42 for Tier 3 $8 for Tier 2 $84 for Tier 4 27% for Tier 5

$2 for Tier 1 $42 for Tier 3 $8 for Tier 2 $84 for Tier 4 28% for Tier 5

$4 for Tier 1 $47 for Tier 3 $14 for Tier 2 $91 for Tier 4 27% for Tier 5 $5 for Tier 1 $105 for Tier 3 $20 for Tier 2 $210 for Tier 4 Tier 5 is not available $10 for Tier 1 $118 for Tier 3 $35 for Tier 2 $228 for Tier 4 Tier 5 is not available

$4 for Tier 1 $47 for Tier 3 $14 for Tier 2 $91 for Tier 4 28% for Tier 5 $5 for Tier 1 $105 for Tier 3 $20 for Tier 2 $210 for Tier 4 Tier 5 is not available $10 for Tier 1 $118 for Tier 3 $35 for Tier 2 $228 for Tier 4 Tier 5 is not available

INITIAL COVERAGE 30-Day Supply Preferred Pharmacy or Mail Order Pharmacy 30-Day Supply Standard Pharmacy 90-Day Supply Preferred Pharmacy 90-Day Supply Standard Pharmacy 31 to 90-Day Mail Order Pharmacy

$0 FOR TIER 1 $0 for Tier 1 $105 for Tier 3 $20 for Tier 2 $210 for Tier 4 Tier 5 is not available

90-Day Mail Order Pharmacy

$0 for Tier 1 $105 for Tier 3 $20 for Tier 2 $210 for Tier 4 Tier 5 is not available

COVERAGE GAP You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

CATASTROPHIC COVERAGE You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

BENEFIT Premium Deductible Annual Deposit from Medicare

NetworkPrime $0 $5,100 You pay nothing for Medicare-covered services after you meet your deductible.

This amount is prorated based on the month you enroll.

Medicare will deposit $1,500 into your account prorated based on when you enroll. If you disenroll for any reason during 2019, you’ll be asked to pay back a prorated amount based on the date you disenroll.

Services (like hospital stays, All Medicare-covered services are billed at the Medicare-approved amount until you reach the deductible. You doctor visits and emergency pay nothing after you reach your deductible. room visits) Customer Service 800-378-5234 (TTY 800-947-3529) | Sales Representative 800-983-7587 | networkhealth.com

NetworkPrime (MSA)

NetworkPrime is a Medicare Medical Savings Account (MSA) plan. Here’s how it works.

High-Deductible Health Plan

This is another Medicare Advantage Plan which covers your hospital and medical care (known as Medicare Parts A and B). Once you’ve paid a certain amount for health care (called the deductible), the plan begins paying.

Medicare MSA Plans Have Two Parts

NetworkPrime has a $5,100 deductible and a $0 monthly premium.

Medical Savings Account

This is a special savings account used for health care costs. Once a year, Medicare deposits money into your account, and you can use this money to pay for health care before you meet the deductible.

High-Deductible Health Plan

Medical Savings Account

Medicare deposits $1,500 into this account once a year.

Make Your Choice If you’re currently a Network Health Medicare Advantage Plan member and are happy with your current plan, do nothing. You will be automatically re-enrolled for 2019.

If you’re currently a Network Health Medicare Advantage Plan member and would like to change plans Visit us online at networkhealth.com, select Medicare Plans and select Change My Plan, or contact your local agent for assistance.

Call 866-623-1855 (800-947-3529) and we can complete the short enrollment form for you.

To Enroll in a Network Health Medicare Advantage plan 1. SET UP AN APPOINTMENT

Call 800-983-7587 or 920-720-1280 to set up a time to meet with a knowledgeable and helpful local agent. If you’d like, our agents will even come to your home.

2. SIGN UP ONLINE

Visit networkhealth.com, select Medicare Plans and click Enroll Now to be guided through the enrollment process.

Customer Service 800-378-5234 (TTY 800-947-3529) | Sales Representative 800-983-7587 | networkhealth.com

PPO MEMBER EXTRAS A Complete Fitness Program At No Cost To You

Improve your health and live the life you want with SilverSneakers Fitness. The program is included in most Network Health Medicare Advantage PPO Plans and gives you membership at more than 13,000 gyms nationwide. Designed for all fitness levels and abilities, this program provides the fitness support you need. Visit silversneakers.com for locations.

Hearing Aid

Network Health Medicare Advantage members receive a hearing aid discount with Simpli Hearing, LLC. Members find quality brand name hearing aids discounted to $1,220-$1,985. The discount program includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. To find a provider, visit simplihearing.com.

Coverage That Travels With You

When visiting another U.S. state, you can get care at the same cost you would back home. Regardless of which state you visit, every provider who accepts Medicare beneficiaries is considered in-network. When you travel outside the U.S., you may have coverage in some situations.

In-network when you travel

I switched to Network Health because I wanted personalized service and didn’t want to feel like a number.

Gloria T., Waukesha

Customer Service 800-378-5234 (TTY 800-947-3529) | Sales Representative 800-983-7587 | networkhealth.com

Coverage For Your Smile

Protect your teeth and gums with routine preventive dental care. We partner with Delta Dental Medicare Advantage to include dental care with many of our Medicare Advantage Plans. One cleaning and one exam per year is available with a $30 copayment at an in-network dentist.* Need more dental care? For $35 per month, you can add a dental rider to our plans for additional coverage. To check if your dentist is a provider, visit medicareadvantage.deltadentalwi.com. * Not available with Network Medicare Go (PPO).

A Clear Benefit For Your Eyes

Our vision care benefit with EyeMed will help ensure that you see clearly. All Network Health Medicare Advantage (PPO) Plans include an annual routine eye exam for a $10 copayment at an in-network EyeMed provider. To find an in-network provider visit eyemedvisioncare.com, select Find a Provider and select the Insight Network.

If you have other questions, it’s our job to help. Call 800-378-5234 (TTY 800-947-3529).

Monday–Friday, from 8 a.m. to 8 p.m. From October 1–March 31, we’re available to assist you seven days a week, 8 a.m. to 8 p.m.

Home Telemonitoring

At Network Health, we understand managing an on-going medical condition like heart failure is challenging. That’s why we offer the home telemonitoring benefit. If you’ve been diagnosed with heart failure, this benefit can help you track your health with an easy-to-use monitoring system and phone calls from a member of the home health care team. Your doctor will be involved throughout your care.

In-Home Health Assesments

Network Health offers in-home health assessments at no cost to members who qualify. A doctor or nurse comes to your home to review your medications and talk about any health concerns you may have. The health care professional can also refer you to our care management teams for health plan services that can help you stay healthy.

Nurse Line

Network Health’s Nurse Line is available when you have health care questions any time of the day or night. This free 24-hour phone service is available 365 days a year through Health Dialog. The Nurse Line can be accessed by calling 888-879-8960 (TTY 888-833-4271).

Health Care Concierge Service

Dealing with health insurance can be stressful. We provide friendly, personal service to every one of our members. Our health care concierge team provides solutions to your concerns, and best of all—they are just a phone call away.

Customer Service 800-378-5234 (TTY 800-947-3529) | Sales Representative 800-983-7587 | networkhealth.com

WHY RATINGS MATTER When discussing Medicare Advantage coverage with friends and family, it’s important to compare apples to apples. You need to know both the coverage and service you’ll receive, because your choice is important to your quality of life and health. With so many companies and plans to choose from, how can you know you’re making the right choice?

Medicare rates all health and prescription drug plans each year, based on a plan’s quality and performance.

Medicare’s CMS Star Rating Program helps you know how well your plan and providers are doing. You can use these Star Ratings to compare quality performance to other plans. For 2018, Network Health Medicare Advantage Plans received the following Overall Star Rating from Medicare.

NETWORK HEALTH SCORED 4.5 OUT OF 5 STARS.

Some of the areas Medicare reviews for these ratings include the following.

• How members rate the plan’s services and care • How well the plan’s providers detect illnesses and keep members healthy • How well the plan helps members use recommended and safe prescription medications

New 2019 ratings are expected to come out later in October. You can find out more about our Star Rating and other measures including quality and member satisfaction ratings from The Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey results at networkhealth. com, select About Network Health and select How We Rate. You can also request a printed copy of these ratings by calling our health care concierge team.

Every year, Medicare evaluates plans based on a 5-star rating system.

800-983-7587 TTY 800-947-3529 Monday–Friday, 8 a.m. to 8 p.m.

From October 1-March 31, we’re available to assist you seven days a week, from 8 a.m. to 8 p.m. networkhealth.com

Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. This information is not a complete description of benefits. Call 800-378-5234 (TTY 800-947-3529) for more information. Out-of-network/non-contracted providers are under no obligation to treat Network Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Y0108_1181-01a-0818_M Accepted 9/16/18 Customer Service 800-378-5234 (TTY 800-947-3529) | Sales Representative 800-983-7587 | networkhealth.com