Perspectives-Spring / Summer 2014

Dolly Goel, MD

I get some natural vitamin D from the sun by exercising outdoors walking my little 7 pound dog - he may be small, but he can run! Always remember to stay hydrated and use sunscreen when outdoors throughout the year. When I can’t get outside to exercise, I stay motivated by taking a free VHP Jazzercise class. I love the fun music and learning new moves to keep my heart pumping.

This issue of our newsletter is lengthier as VHP was recently awarded the National Committee for Quality Assurance (NCQA) Interim Accreditation. This requires communication of certain topics to our members annually. The accreditation identifies VHP as a well-managed health plan that delivers high quality care and service. We are incredibly proud to have earned such recognition for providing you with wellSpring/Summer 2014

deserved service and attention.

Wishing you a safe and healthy summer!

A Message from Dolly Goel, MD................1 Take Charge of Your Wellness....................2 Weight Watchers Benefit.............................2 Great on the Grill...........................................3 Grilled Flank Steak with Corn, Black Bean & Avocado Salad....................3 Speaking the Language of Health in Your Preferred Language........................4 VHP Website Resources...............................4 Member Information....................................5 Member Rights and Responsibilities...........6 Department Profile Provider Relations.......8 Choosing & Changing Your Primary Care Physician................................8 Pharmacy Information.................................9 How to Contact the Utilization Management Department.......................10 Care Management Program...................10 Affirmative Statement About Financial Incentives....................................10 Member Grievance...................................11 Quality Management Program................12 Preventive Health Guidelines....................13 Protected Health Information...................14 How to Access Services.............................14 Primary Care Network................................15 Urgent Care Services..................................16

Table of Contents

Member Newsletter

Hello and happy summer! I hope this finds you enjoying in the splendors of Bay Area living. There are certain activities I like to do as the weather gets warm.

I enjoy going out to the SCVMC and the Los Gatos Farmers’ Markets to buy local, fresh Dolly Goel, MD fruits and vegetables.

VHP Chief Medical Officer The Valley Health Plan (VHP) website has a list of farmers markets located in Santa Clara County complete with days, times, and locations.

Perspectives

A Message from

take charge

of Your Wellness

The steps to good health look different for each person. That’s why Valley Health Plan has partnered with Cerner Wellness to offer you a wellness solution to meet your unique needs and wellness goals.

You can use this tool to learn about your health status and how to improve your well-being. You will have access to an annual personal health assessment, health information, a symptom checker, recipes, online workshops, exercise tips, and more!

VHP Rewards You can earn wellness points by completing your personal health assessment, taking online workshops, logging food and water intake, getting your annual health screenings, and more! The more you do, the more you rewards you can earn!

HealthyNow Mobile App Take advantage of our HealthyNow mobile application that automatically syncs to your wellness account to help you track your points and progress.

Reward Level One VHP Workout Towel

VHP Mobile App

Visit vhp.mycernerwellness.com today and empower yourself to improve your health. For more information, visit our website at valleyhealthplan.org or you can call the Health Education Department at 408.885.3490.

Weight watchers Benefit

Stay inspired and motivated despite your busy schedule with an easy to access, supportive environment, which can help you reach your weight-loss goals. VHP offers two options for the Weight Watchers benefit.

1. Use a 10-week meeting coupon pack to be used at a convenient Weight Watchers Center.

Visit www.weightwatchers.com to find a center near you, some offer multiple meeting days and times.

2. Attend Weight Watchers at Work meetings (copay applies) and take advantage of: • Confidential weigh-ins

• Group support with coworkers

• Flexibility of meetings that fit perfectly into the busy workday

• An experienced leader who has lost weight with Weight Watchers

Members can enjoy an annual Weight Watchers benefit limited to one (1) session per calendar year. A second benefit can be requested during that year with proof of attendance to at least 75% of meetings.

For information about the At-Work program or to request coupons, please contact VHP Health Education at healtheducation@vhp.sccgov.org or call 408.885.3490.

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Great on the Grill

It’s grilling season! Try pairing seasonal fruits and vegetables with lean cuts of meat including beef, chicken, pork, or fish. Healthy meals can become a food adventure offering irresistible fire-roasted foods in no time. Best of all, grilling is one of the best ways to load up on flavor without the added fat, oil, and calories.

Try adding flavor by using a glaze, spice mix, marinade, or simply using salt and fresh ground pepper. A citrus-based marinade is especially suited for less tender cuts of meat because citric acid helps tenderize the meat and allows it to take on more flavor.

Lemon, lime or orange juice, garlic, or fresh herbs—used alone or together—can really boost the flavor of grilled foods. Low-fat salad dressings can also double as marinades. Just

marinate meats in a covered container in the refrigerator for 30 minutes up to 24 hours.

The key to grilling is preheating your grill for about 15 minutes before you start cooking to make sure you have the right temperature. Cook your meat over the hottest area to get a nice sear and create a delicious crust on the outside.

Remember to finish over a cooler area of the grill so meats do not overcook.

Cooking utensils are important tools to a successful meal. Choose tongs with long handles as a fork will pierce the meat allowing the sealed juices to escape. Use a grill basket to help keep smaller pieces of vegetables, fish, and meat from falling through the grill rack.

Celebrate the great summer weather and try these tips for a great meal!

grilled flank steak

with Corn, Black Bean & Avocado Salad

© 2014 Weight Watchers International, Inc. © 2014 WeightWatchers.com, Inc.

Ingredients

Salad

1 pound lean flank steak 1 clove of garlic, peeled and smashed with side of a knife 1 tsp fresh lime juice 1/8 tsp table salt 1/8 tsp black pepper

1 Tbsp. jalapeño pepper, minced (do not touch seeds with bare hands) 1 corn on the cob, cooked, kernels removed ½ medium avocado, peeled, pitted and diced 1 cup canned black beans, drained and rinsed 4 tsp fresh lime juice 2 Tbsp. cilantro, minced 1/8 tsp table salt 1/8 tsp black pepper

Instructions (Prep time: 20 min | Cook time: 11 min | Serves: 4) Immediately remove steak from Preheat grill to medium hot.

Combine salad ingredients in a grill and set aside for 5 minutes medium bowl; stir gently and set Score steak on one side by for meat to reabsorb juices. aside. making shallow crisscross slashes with a sharp knife.

Thinly slice steak across the Grill steak for 5 minutes on first grain and serve with salad. side; flip and grill until wellRub garlic over cut surface of browned on outside and mediumsteak, brush with lime juice, and rare inside, about 5 to 6 minutes season with salt and pepper. more.

Set meat aside for 10 minutes to Yields about 3 ½ ounces of steak and ½ cup of salad per serving PointsPlus Value 7 allow meat to absorb flavors.

WEIGHT WATCHERS and PointsPlus® are the registered trademarks of Weight Watchers International, Inc. and are used under license by WeightWatchers.com, Inc.

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speaking the language of health In Your Preferred Language

English Speaking the language of health…In Your Preferred Language As a member, Valley Health Plan can help you in your language at no cost. If you would like to talk to us or ask for information in your language, please call 1.888.421.8444 during business hours.

Spanish Le servimos…En el idioma de su preferencia Como miembro, Valley Health Plan puede ayudarle en su idioma sin costo alguno. Si desea hablar con nosotros o recibir información en su idioma, por favor llame al 1.888.421.8444 durante horas de oficina.

Vietnamese Chúng Tôi Chăm Sóc Sức Khỏe Cho Qúy Vị… Bằng Ngôn Ngữ của Qúy Vị Là hội viên, Valley Health Plan có thể giúp qúy vị bằng ngôn ngữ của qúy vị miễn phí. Nếu qúy vị muốn nói chuyện với chúng tôi hoặc yêu cầu thông tin bằng ngôn ngữ của qúy vị, xin vui lòng gọi 1.888.421.8444 trong giờ làm việc.

VHp website

Resources

Discover the benefits of being a VHP Member and learn about how to access services, where you can go for care, and how you can improve your health. Visit www.valleyhealthplan.org for the following information: • Combined Evidence of Coverage & Disclosure Form (EOC) • Frequently Asked Questions (FAQs) • Health Education class schedule • How to read your ID card • Member newsletters and updates • Member Rights and Responsibilities • Personal Health Assessment (PHA) • Pharmacy & Formulary information • Protected Health Information • Provider Search • Summary of Benefits and Coverage (SBC) If you have questions or would like to request a printed copy of any materials, please call Member Services at 1.888.421.8444 (toll‐free).

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Member

Information

Is Your Information Up-to-Date?

It is very important that Valley Health Plan (VHP) has your correct address and phone number on file.

We want to make sure you receive our important mailings about additions or changes to benefits, providers/networks, or tools to help you maintain your overall health.

If your information has changed, please call the number that applies to your coverage: Employer Group Plan Members Human Resources Dept.

Covered California Plan Members Covered California Service Center 1.800.300.1506

Individual & Family Plan Members Valley Health Plan Member Services 1.888.421.8444 (toll-free), Option 3

Member Fraud Notice Valley Health Plan (VHP) is committed to providing members with quality care. Please notify VHP of any suspicious activity you might witness while receiving care from a Plan Provider. All complaints regarding fraud will be investigated and necessary actions will be taken to protect members from unlawful activities.

If you believe you’ve experienced or are aware of any type of fraud (waste or abuse of VHP healthcare resources), please contact VHP Member Services Department at memberservices@vhp.sccgov.org or 1.888.421.8444 (toll-free).

Member Updates Periodically, Valley Health Plan sends Member Updates that include information such as benefit information or changes, network additions, changes in policy, and new state regulations. Please keep these updates with your VHP Evidence of Coverage & Disclosure Form (EOC) booklet. These Member Updates along with articles in the Perspectives Newsletter will be your notification of changes related to your contract with Valley Health Plan.

New Technology Review Valley Health Plan has a rigorous process in place to evaluate new technologies that are being developed such as for drugs, medical and behavioral health procedures, and medical devices. VHP’s Utilization Management Committee and Pharmacy & Therapeutics Committee, under the supervision of the VHP Chief Medical Officer, review many areas to make sure that these are safe and effective prior to covering the new technology as a benefit. VHP uses scientific literature, peer-reviewed journal articles, information from medical societies, and government agencies such as the Food and Drug Administration (FDA) to make decisions. New technology that has not been initially approved because its safety or effectiveness has not been demonstrated can be reviewed in the future when more information becomes available.

Provider Directory Valley Health Plan or a delegated entity (such as a hospital or medical group) credentials all physicians in the network and verifies the background and education of all practitioners. The Provider Directory provides general information on all practitioners. If you would like specific information on a physician such as the medical school attended, residency completed, or board certification status, please contact Member Services at 1.888.421.8444 (toll-free).

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member rights

and Responsibilities

A Member has the right to: 1. Exercise these rights without regard to race, disability, sex, religion, age, color, sexual orientation, creed, family history, marital status, veteran status, national origin, handicap, or condition, without regard to your cultural, economic, or educational background, or source(s) of payment for your care; 2. Be treated with respect and recognition regarding your dignity and your right to privacy; 3.

Expect health care providers (doctors, medical professionals, and their staff) to be sensitive to your needs;

Confidential treatment of information in compliance with state and federal law including HIPAA (including all communications and medical records) pertaining to your care. Except as is necessary in connection with administering the Agreement and fulfilling State and federal requirements (including review programs to achieve quality and cost-effective medical care), such information will not be disclosed without first obtaining written permission from you or your authorized representative;

10. Receive complete information about your medical condition, any proposed course of treatment, and your prospects for recovery in terms that you can understand;

4. Be provided with information about VHP, its services, its practitioners, Plan Providers and member rights and responsibilities;

11. Give informed consent unless medically inadvisable, before the start of any procedure or treatment;

5.

12. Refuse health care services to the extent permitted by law and to be informed of the medical consequences of that refusal, unless medically inadvisable;

Know the name of the Primary Care Physician who has primary responsibility for coordinating your health care and the names and professional relationships of other Plan Providers you see;

6. Actively participate in your own health care, which, to the extent permitted by law, includes the right to receive information so that you can accept or refuse recommended treatment; 7.

Receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse this course of treatment or procedure.

Except for Emergency Services this information will include a description of the procedure or treatment, the medically significant risks involved, alternative courses of action and the risks involved in each, and the name of the Plan Provider who will carry out the treatment or procedure;

8. Full consideration of privacy concerning your course of treatment. Case discussions, consultations, examinations, and treatments are confidential and should be conducted discreetly. You have the right to know the reason should any person be present or involved during these procedures or treatments; 6

9.

13. Readily accessible and ready referral to Medically Necessary Covered Services; 14. A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage; 15. A second medical opinion, when medically appropriate, from a Plan Physician within the VHP Network; 16. Be able to schedule appointments in a timely manner; 17. Reasonable continuity of care and advance knowledge of the time and location of your appointment(s); 18. Reasonable responses to any reasonable requests for Covered Services; 19. Have all lab reports, X-rays, specialist’s reports, and other medical records completed and placed in your files as promptly as possible so that your Primary Care Physician can make informed decisions about your treatment;

20. Change your Primary Care Physician; 21. Review your medical records, unless medically inadvisable; 22. Be informed of any charges (Copayments) associated with Covered Services; 23. Be advised if a Plan Provider proposes to engage in or perform care or treatment involving experimental medical procedures, and the right to refuse to participate in such procedures; 24. Leave a Plan Facility or Hospital, even against the advice of Plan Providers; 25. Be informed of continuing health care requirements following your discharge from Plan Facilities or Hospitals; 26. Be informed of, and if necessary, given assistance in making a medical Advance Directive; 27. Have rights extended to any person who legally may make decisions regarding medical care on your behalf; 28. Know when Plan Providers are no longer under a contractual arrangement with VHP; 29. Examine and receive an explanation of any bill(s) for non-Covered Services, regardless of the source(s) of payment; 30. Voice complaints or appeals about Valley Health Plan or the care it provides; 31. File a Grievance without discrimination through VHP or appropriate State or federal agencies;

A Member has the responsibility to: 1. Supply information (to extent possible) that VHP and its practitioners and providers need in order to provide care; 2. Follow plans and instructions for care that you have agreed to with your practitioner; 3. Behave in a manner that doesn’t interfere with your Plan Provider or their ability to provide care; 4. Safeguard the confidentiality of your own personal health care as well as that of other Members; 5. Accept fiscal responsibility associated with non-Covered Services. Covered Services are available only through Plan Providers in your VHP Network (unless such care is rendered as Emergency Services or is authorized); 6. Cooperate with VHP or a Plan Provider’s third party recovery efforts or Coordination of Benefits; 7. Participate in your health care by scheduling and keeping appointments with Plan Providers. If you cannot keep your appointment, call in advance to cancel and reschedule; 8. Report any changes in your name, address, telephone number, or your family’s status to your employer, Covered California, and a VHP Member Services Representative; and 9. Understand your health problems and participate in developing mutually agreedupon treatment goals, to the degree possible.

32. Know the rules and policies that apply to your conduct as a Member; 33. Make recommendations regarding Valley Health Plan’s member rights and responsibilities policy; and 34. Participate with practitioners in making decisions about your health.

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department profile Provider Relations Our Provider Relations Department is responsible for managing the Provider Network.

The team is made up of four Provider Relations Specialists that are available to assist providers with questions or information about VHP benefits and member needs. The Specialists answer the phone Monday through Friday and also visit provider offices to discuss VHP services and any new Plan developments. The team also has two Credentialing Specialists that ensure that VHP providers meet the qualifications determined by the Plan to meet regulatory and National Committee for Quality Assurance (NCQA) requirements. This process ensures that all providers have been carefully screened and meet industry standards. Our providers are re-credentialed every three years; however, there is ongoing monitoring of licensing and regulatory changes.

For questions about VHP Providers or our Network, contact Member Services at 1.888.421.8444 (toll-free). Member Services works closely with Provider Relations to resolve any issues or respond to questions in a timely manner.

Amarjit Singh, Jamie Albright, Michele Garzoni Welch, Vivian Smith (Manager), Leticia Elisea, Jessica Truong, Rachelle Arquero

choosing & changing

Your Primary Care Physician (PCP) Valley Health Plan (VHP) offers you several ways to choose a Primary Care Physician (PCP). You can make an informed decision and find the right provider for you and your family by: • Visiting www.valleyhealthplan.org to learn about our provider networks using our Provider Search or reading the Access to Services & Network Providers booklet • Talking to our knowledgeable Member Services staff about our providers As a Member, you have the right to change your Primary Care Physician at any time. The change will take effect on the first day of the next month after your request is received. During that time, a new card will be sent to you with the name of your new PCP. It is important that you wait to seek services from your new PCP until the change has become effective or you could be financially responsible.

To choose or change your PCP, contact VHP Member Services at member.services@vhp.sccgov.org or by calling 1.888.421.8444 (toll-free).

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pharmacy Information Immunization Benefits and Services VHP encourages members to get the required immunizations as recommended by the U.S. Preventive Services Task Force to help keep you healthy. Your coverage includes immunizations provided by your Primary Care Physician (PCP) or through a VHP Plan Pharmacy.

Travel immunizations are covered only when received at a VHP Plan Pharmacy or your PCP. (*Please note that travel immunizations received from the Santa Clara County Public Health Travel Clinic at Lenzen are not covered by VHP.) You may have to request a prescription from your PCP for certain travel immunizations.

Consultations at a Plan Pharmacy for travel immunizations are not a covered benefit. Ask your PCP or a Plan Pharmacist to see if a consultation is necessary before seeking services.

Visit www.valleyhealthplan.org to find a Plan Pharmacy near you. For more information, please call Member Services at 1.888.421.8444 (toll-free).

Formulary Review & Updates The Valley Health Plan (VHP) drug formulary is reviewed quarterly and updated by the VHP Pharmacy and Therapeutics (P&T) Committee.

The P&T Committee uses information from many sources to determine the status of each drug. The Committee decisions include adding drugs to the formulary, requiring prior authorization for some drugs, requiring quantity limits or step therapy, the process for generic substitution, therapeutic interchange, or not adding the drug to the formulary. These decisions are based on US Food and Drug Administration (FDA) approval, scientific articles, drug safety, and whether there are other like drugs available that accomplish similar results.

These forms will be reviewed by a pharmacist and/or a physician and approval will be based on established criteria and medical necessity.

VHP posts a drug formulary and a summary of updates to the website quarterly after each VHP P&T meeting. Visit www.valleyhealthplan.org for additional information or to view the drug Formulary, summary of updates, and the EOC online.

If you do not have access to the Internet and would like a printed copy of any material, please call VHP Member Services at 1.888.421.8444 (toll-free).

Navitus Health Solutions Navitus Health Solutions is Valley Health Plan’s (VHP) Pharmacy Benefit Manager (PBM). Navitus Health Solutions administers the pharmacy benefit on behalf of VHP including customer service, formulary maintenance, Prior Authorizations, Exception to Coverage, and drug recall notifications.

If you have any questions, please call VHP Member Services at 1.888.421.8444 (toll-free) to answer your pharmacy benefit questions.

Drug Recall Navitus receives notification from the US Food and Drug Administration’s (FDA) recall posting. Valley Health Plan members and prescribing practitioners affected by a Class II recall or voluntary drug withdrawals from the market for safety reasons will be identified and notified within 30 calendar days of the posting, and within two (2) business days for a Class I recall.

If you would like additional information on a recent recall, please visit www.navitus.com.

For information about VHP P&T Committee, please refer to your Valley Health Plan Benefits and Coverage Handbook – Combined Evidence of Coverage and Disclosure Form (EOC), including additional supplemental pharmaceutical management procedures.

Occasionally, VHP will require your provider to fill out a Prior Authorization form for our Formulary drugs or an Exception to Coverage form for drugs that are not on our drug Formulary.

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How to Contact the Utilization Management Department The Utilization Management Department evaluates and determines coverage for, and appropriateness of, medical care services, providing assistance to members and providers to ensure appropriate use of resources.

To contact the UM Department to receive information about the process or status of authorizations and referrals they can be reached toll-free by calling Member Services at 1.888.421.8444, Monday – Friday 9:00am – 5:00pm PST. Language services are available at any time, for the hearing and speech impaired, call the California Relay Service (CSR) by simply dialing 711 or the 800 CRS number of your modality.

After business hours, weekends, and on holidays, all calls will be returned on the next business day.

care management Program

Valley Health Plan (VHP) is launching two new care management programs designed to work with our Members who have one or more health conditions help to improve their health and quality of life. The programs consist of case management, care coordination, and preventive health education and are FREE for Members who qualify based on medical need.

Disease Management Program staff work alongside your doctor’s treatment plan to help manage medical conditions such as: • Asthma • Bipolar Disorder • Coronary Artery Disease • Chronic Obstructive Pulmonary Disease (COPD) • Depression • Diabetes • Heart failure • Schizophrenia The Complex Case Management Program staff will work with you, along with your caregiver and physician, to coordinate care. This will help make smooth transitions between care settings, assist with community resources including social needs, and provide education. Members with one or more health conditions are eligible for this program.

There are many ways to take part in these programs. A care management program representative may contact you to see if you would like to enroll, your doctor may refer you, or you can refer yourself by calling 1.855.624.5223.

Affirmative Statement

About Financial Incentives

Valley Health Plan affirms that: 1. Utilization Management (UM) decision making is based only on appropriateness of care and service and existence of coverage.

2. The Plan does not specifically reward practitioners or other individuals for issuing denials of coverage.

3. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

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MEMBER

Grievance

At Valley Health Plan (VHP) we take pride in being a memberfocused health plan. Our Member Services Department can assist you in resolving your concerns.

VHP Member Services Representatives can be reached by calling 1.888.421.8444 (toll-free), Monday through Friday between 9:00am to 5:00pm.

If you have a problem or concern and you would like to file a grievance, you can contact the Member Services Department by phone, send a letter or complete a Grievance form and submit it to VHP. Grievance forms are available through VHP, at your provider’s office, and at www.valleyhealthplan.org Send your Grievance to Valley Health Plan, Attention: Grievance Manager, 2480 N. First Street, Ste. 200, San Jose, CA 95131 Alternatively, you may also submit your Grievance online at www.valleyhealthplan.org Please include all pertinent information from your VHP ID Card as well as the details and circumstances surrounding your concern or problem. Providing as much information as possible may eliminate the time required to collect such data. Pertinent information should include any medical records or physician opinions in support of your Grievance. If these are not provided, your medical records may need to be obtained from your Plan Physician or you may need to obtain them from a Non-Plan Physician.

VHP will review your Grievance.

You will be notified of the outcome within thirty (30) calendar days of receiving your Grievance. If the

Grievance involves an imminent and serious threat to your health or the health of your Dependents, including but not limited to, severe pain, psychological wellbeing, potential loss of life, limb or major bodily function, you will be entitled to an Expedited Review.

The Grievance must initially state that you are requesting an Expedited Review. If your grievance meets the criteria for an Expedited Review you will be notified of the outcome or status within three (3) working days of receipt of the Expedited Grievance.

If you are not satisfied with the decision of your Grievance, you may contact the California Department of Managed Health Care (DMHC) by following the procedures outlined below.

DMHC Consumer Help-Line “The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1.888.421.8444 (toll-free) or visit the Web site www.valleyhealthplan.org and use your health plan’s grievance process before contacting the Department. For the hearing and speech impaired, call the California

Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.

The Department also has a toll-free telephone number (1.888-HMO.2219) and a TDD line (1.877.688.9891) for the hearing and speech impaired. The Department’s Internet Web site www.hmohelp. ca.gov has complaint forms, IMR application forms and instructions online.”

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Quality management The purpose of the Quality Management (QM) program is to ensure that Members have access to and receive high-quality timely health care, including medical and behavioral health care, which meet their needs and adheres to recognized standards of care.

QM Program Values The QM program reviews, analyzes, and summarizes data continuously and is aligned with the Valley Health Plan (VHP) mission “To ensure that our members receive quality care and service at the right time, at the right place, by the right provider”. QM program values that help us achieve this vision are: • Caring about the individuals and the families we serve as well as caring for them; • Working in an organization where everyone cares and everyone counts; • Workforce competence to accomplish results and sustain service excellence; and • Respect for our Members by upholding their privacy and dignity.

QM Program Goals and Outcomes QM program goals are to offer high quality care and service that: • Focus on quality measures that make a difference for our Members; • Meets Members’ expectations; and • Ensures medical and behavioral health services are provided in a caring, cost-efficient and accessible manner.

VHP continues to make progress in meeting its QM program goals by reviewing indicators for clinical care and member/doctor satisfaction. Recent results from the Healthcare Effectiveness Data and Information Set (HEDIS) show improvements from 2012 to 2013 in measures such as: • Immunizations for adolescents; • Timely care for infants; • Controlling cholesterol for members with heart conditions; and • Diabetes care.

Member satisfaction rates remained high overall from 2012 to 2013. The 2013 survey findings revealed that 86% of Members gave a positive rating to VHP. 12

Program In 2013, VHP achieved the National Committee for Quality Assurance (NCQA) Interim Accreditation.

This accreditation is the most comprehensive evaluation in the nation and is based on results achieved in a set of clinical and consumer measures.

Accreditation is an indicator of a high quality organization.

QM Program Activities Patient Safety VHP advocates a collaborative approach to foster a culture of patient safety and promote high quality care. VHP monitors clinical performance indicators like practitioner credentialing to ensure a safe delivery system. VHP also monitors the Pharmacy Safety Program to ensure that members get the right type and amount of medication they need, along with notifying members quickly of medication recalls. In the 2013 Member Satisfaction Survey, coordination of care between primary care doctors and behavioral health practitioners was identified as a concern. Some members who received behavioral health care reported that their doctor never receives any information about these services. This concern was referred to the VHP Behavioral Health Management Group (BHMG) that oversees the entire behavioral health program to look for improvement activities. The plan is to have the BHMG get input for community behavioral health practitioners in 2014 and come up with new improvement activities. If you participated in the Member Satisfaction Survey, thank you for your feedback to help improve the health plan and the care it provides.

Access and Availability VHP monitors doctors to ensure that they comply with California’s timely access law. VHP is responsible for ensuring that the network is sufficient to help members receive covered services in a timely manner. Member and provider satisfaction surveys are completed annually to rate doctors in VHP’s contracted medical groups. The Provider Access Appointment Availability Survey is also completed each year. In the 2013 Member Satisfaction Survey, getting appointments with specialists continued to be an area where some members reported difficulty.

VHP is assessing its network of providers and will add available providers to meet members’ needs.

Members experiencing this type of difficulty are encouraged to contact VHP Member Services for assistance at 1.888.421.8444 (toll-free).

Health Management Programs VHP has disease management and complex case management programs available to meet the health care needs of its members with complex health conditions or chronic diseases through communication, education and resources. If you would like more information about VHP’s disease management and complex case management programs, please contact Member Services at 1.888.421.8444 (toll-free).

Performance Measurement Valley Health Plan’s performance is measured through the Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS).

HEDIS is one of the most widely used sets of health care performance measures in the United States.

HEDIS results are used to identify opportunities for improvement and include 75 measures across several aspects of care including Effectiveness of Care, Access/Availability of Care, Use of Services, and Cost of Care. Quality interventions include educational initiatives for both members and providers. VHP has started using these national performance measures.

CAHPS is the national member satisfaction survey that VHP will use to compare its results with other health plans across the United States. VHP will be able to help members get the care that research shows is quality care and to measure member satisfaction as compared to other health plan ratings.

If you are contacted for a survey, please invest the short period of time to give feedback and help make us the plan of choice in the community.

These Preventive Guidelines can be found at www.valleyhealthplan.org under Member Materials > Forms & Resources.

Preventive Health Guidelines

Valley Health Plan (VHP) encourages you to make an appointment with your Primary Care Physician (PCP) every year. Visit www.valleyhealthplan.org to find the recommended preventive health guidelines for screenings and immunizations. These guidelines are updated annually by the VHP Utilization Management Committee that includes practicing physicians. These guidelines are based on those from the Centers for Disease Control (CDC) and the United States Preventive Services Task Force (USPSTF).

If you don’t have access to the internet and would like a copy of the guidelines, please contact Member Services at memberservices@vhp.sccgov.org or 1.888.421.8444 (toll-free).

VHP welcomes your feedback and suggestions on how to improve performance. If you have any recommendations or comments on this or other VHP documents, please contact Member Services at 1.888.421.8444 (toll-free).

Preventive Health and Clinical Practice Guidelines Preventive health and clinical practice guidelines are reviewed and updated annually using the most current and reasonable published medical evidence and the U.S. Preventive Services Task Force recommendations. These guidelines help VHP doctors, staff and members to make decisions about the appropriate health care for the members’ medical condition. In the future, VHP will be scored during the NCQA accreditation process on how VHP helps members get the care that research shows will help you stay healthy or be healthier.

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Protected health

Information

Valley Health Plan does not share your health information with anyone without your authorization, unless we are permitted to do so by law.

VHP is committed to protecting your health information. We understand that information about you and your health is confidential and personal.

VHP creates and maintains a record of the care and services you receive through Valley Health Plan. This record is necessary in order to provide you with quality care and to comply with certain legal requirements. The VHP Privacy Notice can be found at www.valleyhealthplan.org/Pages/ PrivacyNotice and includes a full list of your rights and how VHP uses your health information.

We are required by law to: • Make sure that Protected Health Information (PHI) that is linked to you is kept private and confidential (with some exceptions); • Give you a Privacy Notice about VHP’s responsibilities and privacy practices about your PHI; and • Follow the terms of the Privacy Notice that is currently in effect.

VHP is very serious about staff access to your PHI. Information is shared on a need-to-know basis only and discussions regarding PHI are not held in common areas. Staff is trained upon hire about protecting PHI and all the safeguards around oral, written, and electronic access. All written documents that contain PHI are kept locked when not in immediate use. When no longer needed, written PHI is placed in locked shred bins. All electronic PHI is safeguarded with passwords particular to employees who need access to perform job functions, and these passwords must be periodically changed. VHP has firewalls and monitors access to the system to prevent inadvertent loss of PHI. Inappropriate access or use of PHI by employees may result in immediate dismissal.

The VHP website is available to provide members with information regarding their health coverage.

Some information may be collected and stored regarding your site visit only, such as the date, time and number of visits. No identifying information is collected.

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VHP may use, share or disclose your PHI when necessary as required by law and for treatment,

payment, and other health care operations. The law limits how VHP can use and disclose some PHI related to treatment of drug and alcohol abuse, HIV infection, and mental illness. Your medical and/or behavioral health provider also maintains a record of your care. If you wish to access this record, please contact your provider.

Unless permitted by law, VHP will not use or share your PHI unless you have signed an authorization form that allows VHP to do so. You have the right to cancel the permission by notifying VHP in writing, although VHP may have used or shared your PHI when you first gave permission to do so.

You may elect to share your PHI information with an authorized representative such as a friend, family member or anyone of you designate. In order for this type of sharing to happen you must fully complete “The VHP Authorization for Use or Disclosure of Protected Health Information” form.

This form will be placed in your file and VHP will follow your instructions on what information can be shared. All members 18 years of age or older wishing to share their PHI must complete this form. For a copy of this form, please contact VHP Member Services at 1.888.421.8444 (toll-free).

If you have any questions about PHI, the Privacy Notice, or for more information, please contact VHP Member Services Department at memberservices@vhp.sccgov.org or 1.888.421.8444 (toll-free), Monday – Friday, 9:00am – 5:00pm.

How to Access Services

Members are encouraged to seek care within a preferred provider network to make sure medical care is coordinated. Your Primary Care Physician (PCP) is part of a medical group that includes a network of preferred Plan Providers for pharmacy, hospital, laboratory, urgent care, and mental health. Should necessary services be unavailable within your network, VHP will work with you or your PCP to refer you to a contracted provider to meet your access and health care needs.

Primary care

Network Community Clinics

AACI | Foothill Community Health | Gardner Family Health | Indian Health Centers | Mayview Community North East Medical Services | Planned Parenthood Benefit Plan

Medical Group Pharmacy Network

Covered California Plan

Walgreens

Employer Group Plan

Safeway

Individual & Family Plan

SCVMC

Medical Group Hospital

SCVMC

Medical Group Laboratory Network

Medical Group Urgent Care Network*

Medical Group Mental Health Network*

SCVMC

SCVMC

Quest Labs

US HealthWorks

See VHP Directory

Medical Group Laboratory Network

Medical Group Urgent Care Network*

Medical Group Mental Health Network*

SCVMC

SCVMC

Quest Labs

US HealthWorks

See VHP Directory

Independent provider Benefit Plan

Medical Group Pharmacy Network

Covered California Plan

Walgreens

Employer Group Plan

Safeway

Individual & Family Plan

SCVMC

Medical Group Hospital

SCVMC

Northern Cal Advantage medical group (NCAMG) Benefit Plan

Employer Group Plan

Medical Group Pharmacy Network Walgreens Safeway

Medical Group Hospital

Medical Group Laboratory Network

O’Connor

Quest Labs

Medical Group Urgent Care Network*

Medical Group Mental Health Network*

SJMG Willow Glen

See VHP Directory

US HealthWorks

Palo Alto Medical Foundation (PAMF) Benefit Plan

Employer Group Plan

Medical Group Pharmacy Network Walgreens Safeway

Medical Group Hospital

Medical Group Laboratory Network

Medical Group Urgent Care Network*

Medical Group Mental Health Network*

El Camino

PAMF Quest Labs

US HealthWorks

See VHP Directory

Santa Clara county individual practice association (sccipa) Benefit Plan

Employer Group Plan

Medical Group Pharmacy Network Walgreens Safeway

Medical Group Hospital SCVMC

Medical Group Laboratory Network

Medical Group Urgent Care Network*

Medical Group Mental Health Network*

SCVMC

SCVMC

Quest Labs

US HealthWorks

See VHP Directory

Santa Clara valley medical center (scvmc) Benefit Plan

Medical Group Pharmacy Network

Covered California Plan

Walgreens

Employer Group Plan

Safeway

Individual & Family Plan

SCVMC

Medical Group Hospital

SCVMC

Medical Group Laboratory Network

Medical Group Urgent Care Network*

Medical Group Mental Health Network*

SCVMC

SCVMC

Quest Labs

US HealthWorks

See VHP Directory

San jose medical group (SJMG) Benefit Plan

Employer Group Plan

Medical Group Pharmacy Network Walgreens Safeway

Medical Group Hospital O’Connor

Medical Group Laboratory Network

Medical Group Urgent Care Network*

Medical Group Mental Health Network*

SCVMC

SJMG Willow Glen

Quest Labs

US HealthWorks

See VHP Directory

*Visit www.valleyhealthplan.org to find additional Providers or Facilities available for your Medical Group Network.

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Valley Health Plan

2480 N. First Street, Suite 200 San Jose, CA 95131 1.888.421-8444 (toll-free) www.valleyhealthplan.org

© 2014 Valley Health Plan

Urgent care

Services

Urgent Care is care you need within 24 to 48 hours. For urgent medical issues and questions, it is always recommended that you contact your Primary Care Physician (PCP) or call the toll-free Medical Advice line: Employer Group Plan Members 1.866.682.9492 Covered California Plan Members 1.855.348.9119 Individual & Family Plan Members 1.855.348.9119 If you need Urgent Care Services, call the 24-hour Medical Advice line, schedule an appointment; or go to a VHP Network Urgent Care Clinic. In the event you are out of the Service Area and cannot safely go to your Network Provider, go to the closest urgent care provider. All follow-up care must be received through Plan Network Providers or authorized by VHP.

Urgent Care Services are covered by VHP if: • Your condition meets the definition of Urgent Care Services; and • You obtain Urgent Care Service through your VHP Network Provider; or • You obtain Urgent Care Services while outside the Service Area and the medical care could not be delayed until you return to the Service Area.

VHP has several Urgent Care clinics, including the walk-in clinic locations. For a complete list of Plan Urgent Care Clinics, visit: www.valleyhealthplan.org or call Member Services at 1.888.421.8444 (toll-free).

A Member Services Representative can assist you by either directing your call to a VHP nurse for advice and/or by obtaining approval to seek services with an out-of-network Urgent Care clinic.

Out-of-Network Urgent Care Services If you are within your Plan’s service area, you must go to your Network Urgent Care clinic. If you seek Urgent Care services from out-of-network providers within your Plan’s service area and without a Prior Authorization, VHP will not pay for your care and you will be required to pay for the full cost of the services.

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