Perspectives - Winter | Spring 2016

VHP offers many ways to keep you on track by offering low or no cost classes that include fitness, chronic disease management, and nutrition. Visit www.valleyhealthplan.org under Health and Wellness.

Also, please see page 6 for the article “Take Charge of Your Health and Wellness” for a new way to understand your current health status through an online Personal Health Assessment tool and earn VHP rewards!

Here’s to your better health!

Winter | Spring 2016

A Message from Dolly C. Goel, MD.......... 1 Coordination of Care................................. 2 Authorization Review Criteria and Decision Making Process.................. 2 VHP Advisory Board................................. 3 Change of Address................................... 3 Affirmative Statement About Financial Incentives........................ 3 How to Contact the Utilization Management Department......................... 3 Quality Management Program.................. 4 Take Charge of Your Health & Wellness... 6 Pediatric Asthma Camp Superstuff........... 6

Protected Health Information.................... 7 Reach Fitness........................................... 8 Healthy Living Class ................................. 8 Pharmacy Information............................... 9

Member Rights and Responsibilities...... 10

Table of Contents

Member Newsletter

As the Chief Medical Officer for Valley Health Plan (VHP), I would like to stress the importance of having an annual physical with your Primary Care Physician (PCP).

Each year, things can change with your health status that may or may not present any obvious symptoms.

Knowing what your health is each year can help you avoid more serious health issues or, help to manage any chronic disease you may have.

Perspectives

A Message from Dolly C. Goel, MD

Coordination of Care

Valley Health Plan’s (VHP) mission is to ensure you receive quality care and service at the right time, right place and by the right provider. VHP asks that you play an active role alongside all of your providers to help coordinate your health care. Comprehensive care is a mechanism through which a team of health care professionalsincluding physicians, nurses, pharmacists, behavioral health specialists, community-based organizations, and more-work together to facilitate meaningful interactions within the health care system and improve your health outcomes.

“Care coordination is identified by the Institute of Medicine as a key strategy that has the potential to improve effectiveness, safety, and efficiency of the American health care system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone: patients, providers, and payers”.1 VHP is asking you to tell your doctor what your needs and preferences are ahead of time so your doctor is aware, especially when an emergent situation arises. This also means that you should talk to your doctor to make sure they are receiving information from among your specialists and providers you receive emotional/psychological support. This information helps ensure your doctor provides you with safer and more effective transition of care between other providers.

If your health care providers do not coordinate with

each other, the consequences can be harmful.

For example, medication errors, unnecessary or repetitive diagnostic tests, unnecessary emergency room visits, and preventable hospital admissions and readmissions all lead to lower quality of care, and ultimately, worse health outcomes.

Another way you can help with the coordination of care when needed, is to review and complete the Authorization for Use and/Disclosure of Protected Health Information Form. Your health care provider may ask you to sign the form to allow another doctor or provider to have access to your health records. This form is also available online through VHP website at www.valleyhealthplan.org under Member Materials > Forms & Resources. Your doctor or health care practitioner will be able to explain the importance of completing this form, when it is needed to be completed, and why receiving your information from other health care providers is necessary. By completing this form, you can be assured that appropriate and timely communication will take place between care team members. Most importantly, this will aid in the development of your individualized care plan to meet your health needs and priorities.

Coordinated care between your health care providers can result in good health outcomes and also a more satisfying patient experience for you.

1. AHRQ – Agency for Healthcare Research and Quality. Advancing Excellence in Health Care.

Website: www.ahrq.gov.professionals;prevention-chronic-care/coordination/index.html

Authorization Review Criteria and Decision Making Process

Valley Health Plan (VHP) ensures that medical necessity decisions affecting the health care of Members are made in fair, impartial and are consistent by using objective measurable criteria based on reasonable medical evidence.

Authorization requests are reviewed by the VHP Utilization Management (UM) staff to determine the medical necessity for requested services. VHP uses the following criteria sets to assist in this determination: • Apollo Criteria • InterQual (IQ) • Medi-Cal • Medicare CMS regulations

• Med Impact, Harvard Pilgrim medical necessity criteria and/or Epocrates and MicroMedex

• Milliman Care Guidelines • National specialty boards, published guidelines, clinical studies

Valley Health Plan can provide copies or paraphrase the section when copyright restrictions apply, or the criteria applicable to the specific procedure or conditions requested.

For more information, you can contact the UM Department at 1.888.421.8444 (toll-free), Monday – Friday, 9:00am – 5:00pm PST. 2 Perspectives | Winter - Spring 2016

VHP Advisory Board

What is the VHP Advisory Board?

Advisory Board members may assist Valley Health Plan (VHP) in establishing Public Policy.

Public Policy means acts performed by VHP and its employees to assure the comfort, dignity, and convenience of Members who rely on VHP providers for services. The findings and recommendations of this Public Policy Committee or Advisory Board are regularly reported to VHP’s governing body. A minimum of 51% of the VHP Advisory Board must be VHP Members.

Interested in Serving on the VHP Advisory Board?

If you would like more information, please call Member Services at 1.888.421.8444 (toll-free), Monday through Friday, 9:00am to 5:00pm and ask to speak to Laura Eglesia, Member Services Manager.

Change of Address

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 Department

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

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.

How to Contact the Utilization Management Department

The Utilization Management (U.M.) 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 U.M. Department to receive information about the process or status of authorizations and referrals, call Member Services at 1.888.421.8444 (toll-free), 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. www.valleyhealthplan.com 3

Quality Management Program

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 meets 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 that the right place, by the right provider”. The 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

The 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; • Ensures medical and behavioral health services are provided in a caring, cost-efficient and accessible manner; • Provide culturally linguistically appropriate services; and • Meet regulatory and health plan requirements.

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. In 2014, VHP prepared for the NCQA First Accreditation Survey that was held in January 2015. VHP achieved a three - year accreditation from NCQA in March 2015.

QM Program Activities

Clinical Quality and Patient Safety VHP Quality Improvement programs are designed to support and create a working environment wherein patient’s well-being and safety is the top priority. VHP has a network of providers, practitioners, managers, frontline staff, and other affiliates dedicated to providing and safeguarding excellent levels of care. VHP developed measurable criteria to monitor and improve its existing health care delivery system.

VHP has a number of initiatives and programs aimed toward improving the culture of safety through reduction of redundancies or errors which include: • VHP advocates a team approach within the organization and its network of providers and practitioners.

A collaborative relationship exist between VHP, providers and practitioners by sharing the same goal and vision like: Provision of patient-centered, efficient, effective, equitable, safe, and quality care. VHP and its network providers establish performance goal(s) or target and compare them to a reliable benchmark for intuitive and critical data analysis. VHP regularly monitors performance metrics from its network and requires a corrective plan of action when targets are not met.

• VHP monitors clinical performance indicators by having rigorous, credentialing and re-credentialing criteria. This process is used for protecting patients from harm as providers and practitioners are screened carefully before contracting with them. Therefore, please be assured that VHP only commits to the best qualified provider or practitioner.

• VHP monitors medication safety to ensure members receive appropriate medication. The Pharmacy Safety program includes Concurrent Drug Utilization Review (CDUR) and Retrospective Drug Utilization Review (RDUR). The CDUR provides electronic alerts (i.e. drug-drug interactions, high/low dose alert, over/under-use of medication, and therapeutic duplication) that aids pharmacists and providers at the point of sale, and the RDUR provides mailers to providers with member information. The Pharmacy Safety program is provided through our partnership with a Pharmacy Benefit Manager (PBM), Navitus.

4 Perspectives | Winter - Spring 2016

VHP performs regular audits to ensure that members’ pharmaceutical needs are being addressed and the service provided by Navitus meets or exceeds the standards.

• VHP monitors clinical performances, care delivery systems and quality of care through the Consumer Assessment of Healthcare Providers and Systems (CAHPS), which is the annual member and practitioner satisfaction survey. Through the surveys, VHP can reinforce the sufficiency of its network providers and practitioners as well as apply improvement strategies for medical, behavioral, and ancillary services, which in turn, benefits the member. VHP communicates these survey results to VHP administrators, members, executive leaders, frontline staff, and to its network practitioners and providers.

Service Quality

Continuity and coordination of medical and behavioral healthcare is another focus of the VHP Quality Management department. VHP conducted an in depth study for specific behavioral health conditions that our members’ experience along with medications prescribed. As a result, a number of quality improvement opportunities were implemented. As VHP strives to continually improve its services, some of its key operational processes are as follows: Access and Availability - VHP monitors practitioners to ensure California’s Timely Access Regulations are being met. VHP is committed in ensuring that there is a sufficient network of providers and practitioners to meet the needs of our membership in a timely manner VHP can identify medical, behavioral and specialty services which are experiencing timely access challenges. The CAHPS member and provider satisfaction survey are also tools that help monitor timely access issues. Once identified, VHP institutes an immediate action to help the member get the service(s) they needed.

VHP makes necessary adjustments to ensure that there are available practitioners within the network to meet the members’ needs. Members experiencing this type of difficulty are encouraged to contact VHP Member Services for assistance by email at memberservices@vhp.sccgov.org or by calling 1.888.421.8444 (toll-free) Monday-Friday, 9:00am – 5:00pm PST. VHP believes that generating feedback and communication is essential to providing exemplary service to VHP members and practitioners.

Health Management Programs - VHP has a disease management and complex case management programs available to meet the health care needs of its members with complex health conditions or chronic disease through communication, education and the efficient use of available resources. AxisPoint Health, a partner with VHP, directs specific RN Case Managers to work closely with each member by utilizing resources and empowering members to take charge of their own well-being. VHP encourages its network providers to actively refer members whom they find eligible for these programs. Our membership also has access to complete their own Personal Health Assessment on-line, as well as many other programs and resources If you would like more information about VHP’s disease management and complex case management programs, and other available programs, please contact Member Services by email at memberservices@vhp.sccgov.org or by calling 1.888.421.8444 (toll-free) Monday-Friday, 9:00am – 5:00pm PST. Performance Measurements - VHP’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 the 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 practitioners. VHP uses national performance measures to compare our performance to other health plans within the United States.

VHP works hard to improve our ratings and believes that high ratings are an accurate indicator of a high quality health plan. VHP is requesting that if you are contacted for survey in the future, please invest a few minutes of your time and complete the survey. Remember, your feedback is important as it helps VHP to improve our processes and be the plan of choice in the community.

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 by email at memberservices@vhp.sccgov.org or by calling 1.888.421.8444 (toll-free) Monday - Friday, 9:00am – 5:00pm PST. www.valleyhealthplan.com 5

Take Charge of Your Health and Wellness

VHP offers a free online wellness portal to our Members, including an easy 15-minute Personal Health Assessment (PHA) that will help you understand your current health status.

Take charge of your health and visit vhp.mycernerwellness.com to: track your wellness points and earn rewards

• Take your PHA and get your health and wellness recommendations; • Chat with a certified personal trainers and registered dietitians; • Access exercise video clips and online health topic workshops; • Sync the mobile app and Fitbit ® compatible tools to track exercise, food & water intake; • Find healthy recipes and meal plans for special diets; and • Start earning wellness points toward reward levels

Sling Bag

Level 1

Hat

Umbrella

Level 4

Level 3

with Shoe Wallet and Cell Phone Card Holder

Level 2

Portable Charger

For more information, contact the Health Education Department at healtheducation@vhp.sccgov.org or call 408.885.3490.

Camp Superstuff 2016 Asthma Summer Camp

Every summer, Breathe California offers a weeklong asthma day camp called Camp Superstuff.

This camp is designed for children ages 6-12 suffering from asthma. Camp Superstuff blends an asthma education program along with traditional summer camp activities like field trips, games, arts & crafts, skits, songs and more! Camp Superstuff utilizes trained staff and volunteers to teach campers important techniques critical to managing their asthma. This includes: • Understanding different aspects of the disease • Recognizing the triggers of asthma attacks • Knowing when/how to take your medication • Learning how to support your asthmatic peers

When:

Monday, July 18 - Friday, July 22, 2016 9:00 am - 5:00pm

Where: Mayfair Community Center

2039 Kammerer Avenue San Jose, CA 95116

Cost:

Free for all qualified VHP Members

Deadline for Registration Friday, June 24, 2016 (Space is limited.)

Mandatory Parent Orientation When: Friday, July 1, 2016

9:00 am - 5:00pm

Where: Valley Specialty Center Basement,

Room BQ160 751 S. Bascom Avenue San Jose, CA 95128

For more information or to register for the 2016 Camp Superstuff, call Breathe California at 408.998.5865 or the VHP Health Education Department at 408.885.3490.

6 Perspectives | Winter - Spring 2016

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.

We understand that information about you and your health is confidential and personal. We are committed to protecting health information about you. We create and maintain a record of the care and services you receive through Valley Health Plan (VHP). We need this record to provide you with quality care and to comply with certain legal requirements.

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 our responsibilities and privacy practices about your PHI; and • follow the terms of the Privacy Notice that is currently in effect.

Unless permitted by law, VHP will not use or share your PHI unless you have signed an authorization form that allows us to do so. You have the right to cancel the permission by requesting it in writing, except if we have used or shared your PHI when you first gave us permission to do so. The law limits how we can use and disclose some PHI related to treatment of drug and alcohol abuse, HIV infection, and mental illness.

VHP may use, share or disclose your PHI when necessary as required by law and for treatment, payment, and other health care operations.

You may elect to share your PHI information with an authorized representative such as a friend, family member or anyone you choose. For this type of sharing to happen, you must 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 to share.

All members 18 years of age or older wishing to share their PHI, must complete this form. For a copy of this form, you can visit the VHP website at www.valleyhealthplan.org/sites/ccp/mm/ FormsResources/Pages/Resources.aspx or contact VHP Member Services at 1.888.421.8444 (toll-free).

You have the right to request that health care communications regarding sensitive services you receive be sent to an alternate address.

These sensitive services can include, but are not limited to, services and treatment for mental health, pregnancy, sexually transmitted diseases, sexual assault, drug or alcohol treatment, HIV and counseling. Members 12 years of age and older can request that Sensitive Service Confidential Communications be sent to an alternate address by contacting VHP Member Services at 1.888.421.8444 (toll free).

The VHP website provides Members with information regarding their health coverage.

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

The complete VHP Privacy Notice including a list of your rights and how VHP uses your health information can be found on the VHP website at: www.valleyhealthplan.org/Pages/ PrivacyNotice.aspx If you have questions about this Privacy Notice, please contact Valley Health Plan Member Services at 1.888.421.8444 (toll-free), Monday – Friday, 9:00am – 5:00 pm.

Member Fraud Notice

Valley Health Plan (VHP) is committed to providing Members with quality care. We encourage Members to notify VHP of any suspicious activity you might encounter while receiving care from one of our practitioners or providers. All complaints regarding fraud will be investigated. This will allow VHP to take the necessary actions to protect Members from unlawful activities.

If you believe you’ve experienced or are aware of any fraud (waste or abuse of VHP health care resources), please contact Valley Health Plan Member Services at 1.888.421.8444 (toll-free), Monday – Friday 9:00am – 5:00pm.

www.valleyhealthplan.com 7

Reach Fitness

Valley Health Plan (VHP) has always supported members by offering a variety of health and wellness offerings at low or no cost. To further meet this goal, we have a new fitness partner, Reach Fitness, who will provide a new schedule of classes that meet today’s fitness industry standards.

Effective April 1, 2016, VHP and Reach Fitness launched a new fitness program that will allow you, as a member, to access classes that are located throughout Santa Clara County. These new offerings include classes like Zumba® and Bollywood as well as conditioning classes like High Intensity Interval Training (H.I.I.T), Sports Conditioning, and more.

Classes are offered for all fitness levels.

To view class information/updates and for registration information, go to www.valleyhealthplan.org under the Health and Wellness tab.

About Reach Fitness

“Reach Fitness was founded in 1982 as a fitness company focused on building a community around health and fitness for its members. We accomplish this by combining our fitness and wellness experience with an acute understanding of the culture and needs of the clients we serve. Reach is a recognized leader in the field of group exercise. Reach has taught over 200,000 classes in all types and styles. We offer a variety of both indoor and outdoor fitness programs for all levels and interest.

Reach Fitness creates a strong workforce through group exercise programs that will promote, create and foster active and healthy behavior.” – Reach Fitness

We Are Here To Help!

If you have any questions or need assistance, please contact the VHP Health Education Department by email at healtheducation@vhp.sccgov.org or give us a call at 408.885.3490.

Healthy Living Class Eat What’s in Season

Join two Registered Dietitians for an evening of active learning and a light, healthy dinner.

In this class, there will be a cooking demonstration and tastings from a Community Supported Agriculture (CSA) box with recipes to showcase how to prepare produce. Learn where to buy local seasonal produce, as well as how to effectively prepare and store fruits and vegetables to expand its shelf life.

All attendees will receive a complimentary gift and have a chance to win a CSA box.

When:

Wednesday, May 11, 2016 | 5:30pm – 7:30pm

Where:

Sobrato Center for Nonprofits | Cupertino Room A 1400 Parkmoor Avenue, San Jose, CA 95126

To Register:

Contact the VHP Health Education Department at 408.885.3490 In partnership with

8 Perspectives | Winter - Spring 2016

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.

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 Prescription Drug Prior Authorization Request Form for drugs that have Prior Authorization criteria or are not on the VHP Formulary. These forms will be reviewed by a pharmacist and/or a physician and approval will be based on established criteria and medical necessity. www.valleyhealthplan.com 9

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;

9. 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 costeffective medical care), such information will not be disclosed without first obtaining written permission from you or your authorized representative;

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

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. 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;

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;

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; 10 Perspectives | Winter - Spring 2016

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; 32. Know the rules and policies that apply to your conduct as a Member;

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 agreed upon treatment goals, to the degree possible.

33. Make recommendations regarding Valley Health Plan’s member rights and responsibilities policy; and 34. Participate with practitioners in making decisions about your health.

www.valleyhealthplan.com 11

Valley Health Plan 2480 N. First Street, Suite 200 San José, CA 95131 1.888.421.8444 (toll-free) www.valleyhealthplan.org

© 2016 Valley Health Plan

VHP CHIEF MEDICAL OFFICER Dolly C. Goel, MD VHP MEDICAL ADVISORS Stephen Harris, MD Michael Meade, MD Gary Steinke, MD BOARD OF SUPERVISORS Cindy Chavez Dave Cortese S. Joseph Simitian Mike Wasserman Ken Yeager COUNTY EXECUTIVE Jeffrey V. Smith Find us on Social Media!

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