MEMBER
MESSENGER Winter 2019
In each issue: Provider Updates Benefit Information Finding a Specialist
When do I take my child in?
Advance care planning
What are your wishes?
Diabetic eye exams
FLU SEASON
Benefit changes
Formulary updates
NEW
Member care programs Annual notice
NOMINATE A PROVIDER sanfordhealthplan.com
member portal
WORKPLACE BULLYING
Advance care planning
What are your wishes? Advance care planning is not just for those in their golden years. At any age, a medical crisis could leave you too ill to make your own health care decisions. Even if you are not sick now, planning for health care in the future is an important step toward making sure you get the care you would want, if you are unable to speak for yourself and doctors and family members are making the decisions for you. Advance care planning involves learning about the types of decisions that might need to be made, considering those decisions ahead of time, and then letting others know—both your family and your health care providers—about your preferences. An advance directive also allows you to express your values and desires related to end-of-life care. You might think of it as a living document—one that you can adjust as your situation changes because of new information or a change in your health. It is hard to know what the future is. You may never face a medical problem where you are unable to speak for yourself and make your wishes known. But having an advance directive may give you and those closest to you peace of mind. For more information about health care directives, CLICK HERE.
Flu season is here and we want you to stay healthy!
Even healthy people can get the flu. This season, protect yourself—and those around you—by getting a flu shot. Flu shots are an important preventive measure you can take to stay healthy this winter and are included as part of your preventive benefits. And remember to take everyday preventive actions to stop the spread of germs by washing your hands and stay away from people who are sick. 2
When do I take my child in? When you are a parent, you try to do everything possible to keep your child healthy. When they have been sick for even more than a day, you may feel you need to take them to the doctor. But is this the right answer? If your child has the common cold, there is no antibiotic that can help them feel better. For children four years and older, over-the-counter medicines (OTC) can help. If you are unsure which OTC medicines you should use, ask your child’s doctor. Always call the doctor if you think your child might have more than a cold, your child gets worse instead of better or if your child has any of these symptoms: • C ontinuing fever greater than 100.4°F despite age and weight-appropriate doses of Tylenol® • Coughing up a lot of mucus • Shortness of breath • Unusual lethargy/tiredness • I nability to keep food or liquids down or poor fluid intake • Increasing headache or facial or throat pain • S everely painful sore throat that interferes with swallowing • Chest or stomach pain • Swollen glands in the neck • Earache • Symptoms that are not relieved by over-the-counter drugs1 Like most viral infections, colds just have to run their course. Getting plenty of rest and drinking lots of fluids—juice and water—can help your child fee better while on the mend. Keep in mind that a fever could be your friend as it is your body’s way of fighting the disease. If Tylenol® in an appropriate dosage helps keep the fever at bay, usually it is safe to “watch and wait” to see if they get better in three or so days. However, if Tylenol® doesn’t control the fever, take them in. Remember if you are ever in doubt about what to do, call your doctor. This information is intended to be a guide. 1. Upper Respiratory Infection, Johns Hopkins Medicine. http://www.hopkinsmedicine.org/healthlibrary/ conditions/pediatrics/upper_respiratory_infection_uri_or_common_cold_90,P02966, 10/5/17.
3
Our NEW MEMBER PORTAL is live! Sanford Health Plan’s new member portal empowers you to manage your health care information more easily and efficiently than ever before. The portal is available 24/7 so you can find information you need, whenever you may need it. Access to both your medical and insurance information (if you receive care at Sanford Health and have Sanford Health Plan insurance) is now available from ONE centralized location.
• Convenient access to the Provider and Pharmacy Directory, Wellness, Pharmacy and Flexible Spending Portals is available! Find a new doctor, compare medication costs, take a wellness assessment or submit a flexible spending or HSA claim easily, all from one location.
Insurance information in the portal can be found under the insurance tab. Within that section, you’ll find:
• Check out our various Member Care Programs. We offer a multiple free programs to help you manage your health—including case management, help to quit smoking, a healthy pregnancy program and more.
• R eal time, at-a-glance access to your benefit balances, claim details, authorization information and more, to help you maximize your insurance benefits.
• O ur new portal will provide the ability to provide you with even more functionality in the future; more updates are scheduled for the first half of 2020!
• Insurance resources, tools, and FAQs. We know insurance can be confusing! The portal has built in tools to help you get answers. Need more help? You can easily send us a secure message right from the portal, or give us a call anytime!
Have more questions about the new portal? Need help to sign up? Can’t find something you need? We are happy to help! Please contact a Coverage Concierge at (800) 752-5863 with any questions you may have.
Formulary changes for coming year Formularies that include the 2020 changes are currently available online. To view, CLICK HERE. Note: Members directly impacted by changes have received notification of the change.
4
Do you have diabetes? Diabetic retinopathy is a serious condition that can cause blindness for people with uncontrolled diabetes, but maintaining stable blood sugar levels, as well as getting your eyes checked, can decrease your risk. To help protect your eyes, Sanford Health Plan offers an annual diabetic dilated eye exam benefit as part of your plan. • C overed with a participating ophthalmologist or optometrist (does not include refraction) • Prevent future diabetic complications
Take the following steps to avoid eye problems: • Keep blood glucose levels and high blood pressure under control • Quit smoking • Have a dilated eye exam once a year • See your ophthalmologist or optometrist if you develop any eye problems Be sure to remind your eye care provider that the exam is a covered benefit and ask them to submit your eye exam to your medical insurance and send the results to your primary care doctor.
If you or your provider have questions about your diabetes related benefits, please call Customer Service.
Member care programs Helping you improve your health is important to us and we want to ensure you have what is needed to stay healthy and manage your health. We have developed programs and services, which are here to assist in supporting your needs. These programs and services include medical and behavioral health case management, a health assessment with self-management tools, health coaching, biometric screenings, support for emotional and socially challenging situations and more. Our current programs focus on:
Other resources and available programs:
• P romoting colorectal and breast cancer screenings for eligible members
• Healthy Pregnancy Program
• M embers with chronic obstructive pulmonary disease (COPD), heart failure and coronary artery disease and hypertension to: o Prevent health complications o Provide assistance in managing their health o Ensure their care is coordinated
• Better Choices Better Health Workshops
• Tobacco Cessation Program • Behavioral Health Case Management • S upport for additional preventive health care including cervical cancer screenings and immunizations • M y Sanford Nurse: nurses available to answer your medical questions by email/phone 24/7
For more information about any of the available programs and services or to learn how to enroll in a program, contact Customer Service. 5
BULLYING IN THE WORKPLACE Recent studies have shown that workplace bullying is on the rise. Research has proven that almost 75 percent of employees surveyed had been affected by workplace bullying. The 2017 US Workplace Bullying Survey showed that almost 60 percent of US workers are affected by it. It has also been shown that although workplace bullying is not equally split between men (70 percent) and women (30 percent), women tend to bully more women than men (more than 65 percent in both cases). Workplace bullying can be carried out from coworkers or supervisors. Do we really understand what workplace bullying is? There is not an easy definition of bullying and there is no list of bullying behaviors. However, one definition of bullying can be if a person genuinely feels they are being singled out for unfair treatment by a supervisor or coworker they are probably being bullied. Looking at the effects of workplace bullying, the nearly half (46 percent) of people say that bullying has an impact on their performance at work, and the same amount believe it has a negative effect on their mental health. It knocks the self-esteem of even the most resourceful and confident people, wearing them down so that they are less trusting of their own instincts and judgement and consequently unfit to work. Individuals can feel stressed and struggle with emotional and physical symptoms. People who are bullied can be at an increase risk of depression. How to seek help if you are being bullied: 1. A cknowledge that bullying at your workplace can affect your mental health. 2. S eek the support of your supervisor or human resources if you are not being heard by management. 3. T ake care of yourself by seeking counseling for the effects from the bullying on your emotional and mental health. Counseling can offer support and stress management solutions.
The Behavioral Health Team at Sanford Health Plan can help connect you to a counselor, your employee assistance program or other helpful resources. Contact information email SHPBehavioralHealth@sanfordhealth.org or call (888) 315-0884. 6
Reference: Forbes.com/July 29, 2018
Benefits Update
Possible changes to your benefits As the new year approaches, we want you to be aware of some changes that may affect your benefits. Hearing aids coverage Continuous glucose monitors Available through both a pharmacy (at a Tier 2 copay) or through a durable medical equipment provider (subject to deductible/co-insurance)
01
07
Members under age 19: • No prior authorization required; benefit limit of one hearing aid per member, per ear, every three years Members over age 19: • Prior authorization required; no coverage for gradual hearing loss due to aging Only applies to Large groups, Affordable Care Act (ACA) plans already have this benefit
ND air ambulance
Custom orthotics Covered for certain conditions (like Members under age 18 who need custom for pediatric sizes) per internal medical criteria guidelines
02
08
Only applies to North Dakota plans
Dental appliances • R emoved prior authorization requirement for TMJ splints • Dental appliances, including those for sleep apnea, are excluded
Dental coverage Coverage for dental extractions when certain medical conditions are present
Due to regulation changes, payments made to out-of-network air ambulance providers are no longer considered full and final
03
04
09
10
Nutritional counseling Removed diagnosis criteria for nutritional counseling, total benefit of twelve visits
Prescription drugs – generic $0 copay for prescription drugs less than $6
Prior authorization list updates Exclusion updates • P olishing of prosthetic eye(s) and contact lens fitting fee(s) removed • Addition of non-FDA approved medical cannabis and commodes
05
11
• Prior authorization is required for: o Durable medical o I nsertion, removal equipment with cost and revision of greater than $10,000 implants
Habilitative therapies Covered to a limit of 30 visits per year Only applies to SD Large groups, Affordable Care Act (ACA) plans and other Large groups already have this benefit
• Prior authorization is no longer required for: o INR monitor o Biofeedback o Continuous glucose o Dental appliances monitor sensors o Home infusion services
06
12
Telehealth (TRUE) Participants in the Healthy Pregnancy Program may receive a free Tytocare kit. Only applies to Sanford Individual/Small Group TRUE plans
Call Sanford Health Plan if you have questions about these benefit changes. 7
Provider Update To see the most current list of providers, visit sanfordhealthplan.com/ memberlogin
Benefit Information For additional Health Plan benefit information, visit sanfordhealthplan.com/ memberlogin or call Customer Service at (800) 752-5863.
Finding a Specialist If your doctor refers you to a specialist, but the specialist is not available as soon as you would like, you have options. Ask the clinic if a similar specialist is available or call Sanford Health Plan Customer Service.
NOMINATING A PROVIDER Is your primary care provider, counselor, psychologist or psychiatrist not contracted with Sanford Health Plan? Did you know you can nominate them online or by calling customer service? Follow the instructions HERE to complete the nomination request.
CONTACT US memberservices@ sanfordhealth.org (800) 752-5863 TTY: (877) 652-1884
Sanford Health Plan will contact the provider you have nominated to see if they are interested to start the credentialing process. We cannot guarantee that the nominated provider will choose to participate. You will receive a letter confirming your nomination request has been received. We encourage you to follow up with your provider as well.
Language Line: (800) 892-0675
Annual notice
Watch for your annual Sanford Health Plan Annual Notice. This notice contains important information about your plan, including how and where to find coverage documents, how to sign up for one of our member health programs, services that require pre-approval, care setting information, the member appeal and complaint process, network information, federal rules, regulations, privacy information and more. If you did not receive your notice, please contact Sanford Health Plan to request a copy. SVHP-2876 Rev. 11/19