May 2012
In This Issue:
- Are You Covered?
- When Quitting is OK!
PAGE 2
- Your Health Is Our Priority
- Always Available To Our Members
PAGE 3
- Medical Treatment the Way
YOU Want It
- Preventing Injuries in
Your Home
PAGE 4
- Learn What is New This 2012
Hurricane Season and Then
Get Prepared!
PAGE 5
- Help Your Doctors Help You
- Dealing with Diabetes
PAGE 6
- Avoiding Health Care or
Health Insurance Fraud
- Prediabetes and You
PAGE 7
- Concierge Service & Locations
PAGE 8
Dental and Vision Services:
Are you Covered?
them compare the plan’s covered service list to
I
f your plan includes benefits for Dental their suggested services. and Vision Services, you will want to knowwhat services are paid for by the plan before Network providers will also ask you to sign a starting any treatment. If your doctor suggests “Treatment Plan” before starting any services. any additional services, you will want to verify This is like signing an estimate for car repairs the services are covered. before the mechanic begins the work. Before you sign, make sure you fully understand which The “Additional Medicare Benefits” section of services the plan will cover and those you will your “Evidence of Coverage” book sent to you be responsible for. Please ask the provider for in your new enrollment package will explain assistance if you have any questions. If the services the plan covers. Only the services provider is unable to help you, please contact listed as covered services will be paid by the the plan and ask for assistance BEFORE signing plan. Some services have quantity or time the form. Once you sign the form, you agree to limitations. For example, some plans that be responsible for any amounts not paid by your provide benefits for Dental Services have a limit insurance plan.
of 2 fluoride treatments per year.
You also have the right to get a second opinion If your plan includes benefits for Dental and/or if you do not feel comfortable with a provider’s Vision Services, the services are listed by a proposed treatment plan. If you wish to obtain a procedure code in your Evidence of Coverage second opinion, please contact the plan to make to help identify the exact service. If you are still arrangements.
unsure if a certain service will be paid by your
plan, you can ask your provider for help. Have If you have any questions about your benefits
for Dental or Vision Services, please contact the plan’s Member Services Department for more information.
Preventive Health:
When Quitting is OK!
W
hether you are a smoker or nonsmoker, breathing in tobacco smoke puts you at risk for many different health problems, including cancer, emphysema, heart disease, asthma and allergies.If you do smoke, please be respectful of others around you who do not
smoke. For example, go outdoors to smoke, don’t smoke in a car with • If you have access to the internet, check out the American Lung nonsmokers, and most importantly, consider quitting altogether. Your Associations’ Freedom from Smoking Program at www.lung.org/stop family members will appreciate your efforts to keep them and yourself safe smoking/.
and healthy. Be a winner-quit smoking now. • Other online resources are: www.smokefree.gov
www.quitnet.com
There are many places to go for help with the process of quitting smoking. Telephone Quit Lines-Call for free one-on-one help from information It may be a difficult process, but it could save your life and your family
specialists: member’s lives. Remember, you are not alone-your providers will be more
than happy to discuss your options for quitting. Also: • Cancer Information Service Quit Line 1-800-4 CANCER (1-800-422-6237)
• Check with your local health department about helping you become a • American Lung Association Freedom From Smoking Quit Line nonsmoker. 1-800-LUNG-USA (1-800-586-4872)
O
ur goal is to help our members improve their health by providing the best care and service options. In order to do this, we rely on our Quality Management (QM) Program, which monitors the quality of care and services given by plan doctors and other providers. The QM Program also looks for areas that need to be improved in medical and preventive services, and performs outreach and health education activities to our members.Every year, we look closely at the Quality Management Program to see the progress we have made toward meeting our goals for healthy members. One of the tools we use to do this is called HEDIS, which stands for
Healthcare Effectiveness Data and Information Set. HEDIS is a very common tool used by health care plans to see how well they are serving their members. We use these HEDIS results to see where we need to focus our improvement efforts.
You can view our “report card” at the following website:
• http://reportcard.ncqa.org/plan/external/plansearch.aspx
For more information on how the plan performs on HEDIS, visit the following websites:
• Agency for Healthcare Administration (AHCA):
http://www.floridahealthfinder.gov/HealthPlans/Default.aspx
• The Centers for Medicare and Medicaid Services (CMS): www.medicare.gov
You can call Member Services to request more information about our Quality Management Program.
Quality Management Program:
Your Health is Our Priority
Always Available to our Members
(www.youroptimumhealthcare.com)
O
ptimum HealthCare offers a lot of information for our members on our website, including resources and programs available to members. Please check our website, using the links below, for information available on the following topics:Case & Disease youroptimumhealthcare.com -> about optimum -> utilization & quality
Management Programs
Clinical Health youroptimumhealthcare.com -> about optimum -> utilization & quality -> clinical health guidelines
Guidelines
Grievance & Appeals youroptimumhealthcare.com -> quick links -> grievance & appeals
Medical Record youroptimumhealthcare.com -> about optimum -> utilization & quality -> medical record standards
Standards
Newsletters youroptimumhealthcare.com -> tools & resources -> Newsletters
Patient Safety Programs youroptimumhealthcare.com -> about optimum -> utilization & quality -> quality management
Preventive Health youroptimumhealthcare.com -> about optimum -> utilization & quality -> Preventive Health Guidelines
Guidelines
Privacy youroptimumhealthcare.com -> quick links -> privacy policy & legal
Quality Management youroptimumhealthcare.com -> about optimum -> utilization & quality -> quality management
Programs
Quality Management youroptimumhealthcare.com -> about optimum -> utilization & quality -> quality management
Performance
Utilization Management youroptimumhealthcare.com -> about optimum -> utilization & quality -> utilization management
Programs
Advance Directives:
Medical Treatment the Way YOU Want it
E
very adult has the right to decide what kind of medical treatmentthey get. If you are too sick to make medical decisions for yourself, Florida law ensures that your personal wishes will be respected. If you are too sick to speak or write, it is wise to have what is called an advance directive on file that states your wishes about your medical treatment. There are three common types of advance directives: a living will, a health care surrogate, and anatomical donation.
A Living Will lets your doctor and family know what kind of medical care you want (or do not want) if you are very ill and cannot make your own choices. A Living Will is your set of
personal instructions about your medical care and treatment.
An Anatomical Donation
is a document that indicates your wish to donate, at death,
all or part of your body. This can be an organ and tissue donation to persons in need, or donation of your body for training of health care workers. You can indicate your choice to be an organ donor by designating it on your driver’s license or state identification card, signing a
uniform donor form, or expressing your wish in a living will.
If you choose to have an advance directive, keep the following guidelines in mind:
• If you designate a health care surrogate, be sure to ask them if they agree to take this responsibility, discuss how you
would like matters handled, and give them a copy of the document.
• Make sure that your health care provider, attorney, and the significant persons in your life know that you have an advance directive and where it is located. You may want to give them a copy as well.
• Set up a file where you can keep a copy of your advance directive (and other important paperwork). Some people keep original papers in a bank safety deposit box. If you do, you may want to keep copies at your house or information concerning the location of your safety deposit box.
• Keep a card or note in your purse or wallet that states that you have an advance directive and where it is located.
• If you change your advance directive, make sure your health care provider, attorney and the significant persons in your life have the latest copy. For more information about advance directives, your patient rights, or to access Advance Directive forms, visit the Florida Agency for Health Care Administration website at: http://ahca.myflorida.com
More resources that may be of interest:
Aging with Dignity - www.agingwithdignity.org (888) 594-7437
This organization has a document called, “Five Wishes” that allows you to specify your instructions on tube feeding, assistance with breathing pain medication, and other comfort measures.
Partnership for Caring - www.partnershipforcaring.org (800) 989-9455
American Association of Retired Persons (AARP)
www.aarp.org (type “advance directives” to search)
Florida Agency for Healthcare Administration
http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/HC_ Advance_Directives/index.shtml
Patient Safety Corner:
Preventing Injuries in your Home
• Keep frequently used items low and close-by so you
Y
ou may think your home is your safety zone, but can reach them without using a step stool or reaching there can be many hidden dangers that can cause an injury over your head.even within your home. Use these tips to make your home
• Make sure area rugs are secure. safer:
• Install grab bars next to your toilet and in your shower. • Make sure there is a clear path from room to room
• Improve the lighting in your home. Install night lights without furniture or other obstructions.
so you can see better at night. • There’s no need to rush for the phone - if it is
• Wear shoes to improve your traction on slippery important, they will call back.
I
t is that time of year to prepare for the 2012 Hurricane Season. For any members who may be new to hurricane-prone areas, let us review some basic hurricane information:- Category 4 Hurricane: Maximum Wind Speed: 130-156 miles per hour; Damage Category: Extreme; Approximate Storm Surge: 13-18 feet
• Have a Disaster Plan prepared for you and your family. If you do not have a disaster preparation guide, you may go to our website at http://www.youroptimumhealthcare. com/ or visit one of our local Concierge offices to pick one up. See the listing on the back of this newsletter for locations. Venues such as your local grocery or home improvement stores will often carry Hurricane Preparation Guides as well.
• If you have special needs, live in an evacuation zone, or intend to use shelter in an emergency, please remember to register with your county emergency management office in advance.
Learn What Is New This 2012 Hurricane Season
and Then Get Prepared!
NEW INFORMATION
FOR HURRICANE
SEASON 2012
HURRICANE 101
• Hurricanes usually occur during the summer and fall months of the year. The Atlantic Hurricane Season lasts from June 1st to November 30th each year. There have been instances where tropical storms and hurricanes have formed earlier or later.
• Hurricanes are tropical storms that form where the trade winds come together, gain strength to wind speeds of 74 mph, and even higher depending on how strong they become. • Hurricanes are divided into 5 Categories
with the following effects:
- Category 1 Hurricane: Maximum Wind Speed: 74-95 miles per hour; Damage Category: Minimal; Approximate Storm Surge: 3-5 feet
- Category 2 Hurricane: Maximum Wind Speed: 96-110 miles per hour; Damage Category: Moderate; Approximate Storm Surge: 6-8 feet
- Category 3 Hurricane: Maximum Wind Speed: 111-129 miles per hour; Damage Category: Extensive; Approximate Storm Surge: 9-12 feet
- Category 5 Hurricane: Maximum Wind Speed: Above 157 miles per hour; Damage Category: Catastrophic: Approximate Storm Surge: More than 18 feet
• The greatest potential for loss of life related to a hurricane is from the storm surge! Storm surge is simply water that is pushed toward the shore by the force of the winds swirling around the storm. This advancing surge combines with the normal tides to create the hurricane storm tide, which can increase the average water level to heights affecting roads, homes and other critical systems. • Know the difference between a Hurricane
Watch and Hurricane Warning —
Hurricane Watch - Hurricane conditions are a threat within 48 hours. Review your hurricane plans, keep informed and be ready to act if a warning is issued.
Hurricane Warning - Hurricane conditions are expected within 36 hours. Complete your storm preparations and leave the area if directed to do so by authorities.
• Find out if you are located in an Evacuation Zone.
Officials with the National Hurricane Center have a message for residents living in hurricane-prone areas: Do not tape your
windows!
At this year’s National Hurricane Conference in Orlando, Fla., Bill Read, Director of the National Hurricane Center, told hundreds of meteorologists and emergency management officials to encourage residents to skip taping their windows when a hurricane is heading their way. They believe it creates a false sense of security. Taping windows may actually increase danger. Taping windows can create larger and deadlier pieces of glass when winds blow through a home because the tape holds them together, officials say. “You are wasting your time, money and potentially increasing the danger to your home.” Instead, residents should use methods such as hurricane shutters or impact-resistant windows.
Source: RedOrbit.com Meteorologist Joshua Kelly
American Red Cross National Hurricane Center
Diabetes Care:
T
he medicines you take are important to your health. Your doctors and other health care staff work hard to keep you safe and prevent medication errors. But you may be at risk of a medication error when you see more than one doctor. Medication mistakes can happen during transitions between specialists. Someone other than your regular doctor may not be aware of your latest medication information. They could duplicate medicines you already take or give you the wrong dosage. This gap in medication awareness can cause dangerous drug interactions. It is especially dangerous if you are taking a high-risk medication. Medication errors can also happen when you are admitted or discharged from a hospital. Studies show that almost a third of hospital patients experience a medication error. Fourteen percent of patients experience a medication mistake when they are discharged from the hospital.You can avoid a medication error if you take charge of tracking your medications. It is important to make sure everyone involved in your care knows about the medications you take. A medication list can make a big difference in how well your doctors and other providers can help you. A medication list should include:
• all of the medications you take and how often
• any medications prescribed by different doctors
• over-the-counter products you use
• the dosage and instructions for all drugs you are prescribed
• any medication allergies you have
Carry a copy of this list with you in your wallet in case of an emergency hospitalization. Remember to bring your prescription bottles
with you to all medical appointments. Your providers can review your medications and discuss any issues with you. Don’t be afraid to speak up! Ask your health care providers plenty of questions. It is important that you understand any special medication instructions or any follow-up needs. You should also know whom to contact with questions or problems after you are discharged from the hospital. Make sure you attend any scheduled follow-up appointments. Medication errors are a risk all patients face. But you can play a big part in keeping yourself healthy and safe. Simply keep track of your medications and keep your doctors up to date with your medication information.
Data Source: Agency for Healthcare Research and Quality
http://www.psnet.ahrq.gov/default.aspx
Patient Safety Corner:
Help your Doctors Help You
Dealing with Diabetes
L
earning how to manage your diabetes is the key to feeling better and staying healthy. Managing your diabetes means checking your blood sugar several times a day with a blood glucose meter and keeping your blood sugar close to normal with diet and exercise.Eating healthy is an important part of diabetes management. It is not just about what you eat, but also how much you eat and when you eat it. To lessen the amount of change in your blood sugar levels, you should try to eat at the same time every day. You can also eat healthy snacks between meals so your blood sugar level remains consistent. Make every meal well balanced with whole grains, lean protein, and plenty of fruits and vegetables.
Exercise is another important part of your diabetes management plan. Regular physical activity improves your body’s response to insulin. Your muscles use sugar for energy, which means physical activity can lower your blood sugar level. Exercise can also make you feel better, reduce your stress, and increase your energy level. So get moving! Something as simple as taking a walk, doing housework, or gardening can lower your blood sugar level.
Things to remember before you start exercising:
• Talk with your doctor before you start any exercise program.
• Check your blood sugar level before, during, and after exercise. Know the warning signs of low blood sugar.
• Pack a small cooler of healthy snacks in case your blood sugar drops too low.
• Stay hydrated. Dehydration can affect blood sugar levels.
By managing your diabetes with diet and exercise, you can prevent other health problems related to diabetes, such as eye disease, kidney disease, and nerve problems.
Just remember that you are not alone. You have a team of providers who will help you with your goals. They will work with you to help you reach your goals, but it will be up to you to take action! You are in control!
Avoiding Health Care or Health Insurance Fraud
H
ealth Care Fraud or Health InsuranceFraud is one of the most common scams that are investigated. Here are some examples and tips to help prevent you from being victimized.
• Medical Equipment Fraud: Equipment
manufacturers offer “free” products to individuals. Insurers are then charged for products that were not needed and/or may not have been delivered.
• “Rolling Lab” Schemes: Unnecessary and
sometimes fake tests are given to individuals at health clubs, retirement homes, or shopping malls and billed to insurance companies or Medicare.
• Services Not Performed: Customers or
providers bill insurers for services never rendered by changing bills or submitting fake ones.
• Medicare Fraud: Medicare fraud can take
the form of any of the health insurance frauds described above. Senior citizens are frequent targets of Medicare schemes, especially by medical equipment manufacturers who offer seniors free medical products in exchange for their Medicare numbers. Because a physician must sign a form certifying that equipment or
testing is needed before Medicare pays for it, con artists fake signatures or bribe corrupt doctors to sign the forms. Once a signature is in place, the manufacturers bill Medicare for merchandise or service that was not needed or was not ordered.
Tips for Avoiding Health Care Fraud or Health Insurance Fraud:
• Never sign blank insurance claim forms. • Never give blanket authorization to a medical
provider to bill for services rendered. • Ask your medical providers what they will
charge and what you will be expected to pay out-of-pocket.
• Carefully review your insurer’s Explanation of Benefits statement. Call your insurer and provider if you have questions.
• Do not do business with door-to-door or telephone salespeople who tell you that services of medical equipment are free. • Give your Medicare Advantage insurance
identification only to those who have provided you with medical services. (As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get services. Keep your red, white, and blue
P
rediabetes occurs when your blood sugar level is higher than normal but
not quite high enough for a diagnosis of diabetes. Prediabetes can become type 2
Diabetes within 10 years if it is not counteracted through
simple lifestyle changes. Engaging in 30
minutes of modest exercise per day
and dropping 5 to 10 percent of
your body weight are excellent first
steps to slowing down prediabetes.
Even dropping just 5 to 10 pounds
can improve your sugar levels. You
can lower your risk of Type 2 diabetes
by staying at a healthy weight, eating
the right amounts of healthy foods, and
becoming more physically active.
Preventive Health:
Prediabetes and You
Medicare card in a safe place in case you need it later.)
• Never give your Social Security number over the phone, unless you make the call. • Keep accurate records of all health care
appointments.
• Know if your physician ordered equipment for you.
If you suspect fraud or any other potential acts of non-compliance, please contact us. There are several ways you can report:
• Compliance Hotline: 1-888-548-0094
This is a private line. You can leave a message without your name. If you leave your name and phone number, we will call you back to make sure we have all the information.
• Compliance Email:
ComplianceReporting@americas1stchoice. com
• Compliance Fax: 1-888-548-0092
• Mail: Optimum HealthCare
Attn: Compliance Reporting P.O. Box 152137Ê
Tampa, FL 33684Ê
Your information will be confidential. Reporting fraud and abuse will not affect the medical services you receive or your membership with the Plan.
You can also contact other agencies to report fraud and abuse.
Office of Inspector General (OIG) Fraud Hotline Phone: 1-800-HHS-TIPS (1-800-447-8477) TTY: 1-800-377-4950 FAX: 1-800-223-8164 EMAIL: [email protected]
Address: HHS Tips Hotline
P.O. Box 23489
Washington, DC 20026-3489
Florida Attorney General
Phone: 1-866-966-7226
Department of Financial Services, Division of Insurance Fraud
May 2012
Wellness
Member Newsletter
Living
Health &
P.O. Box 151137, Tampa, FL 33684
Information
Concierge
Service Locations:
Brevard/Orange/Osceola/Seminole
950 S. Winter Park Dr., Ste. 340 Casselberry, FL 32707 Phone: (407) 965-2684 Toll Free: 1-888-364-7905
Charlotte/Manatee/Sarasota
3874 E. SR 64, Bradenton, FL 34208 Phone: (941) 708-0850 Toll Free: 1-888-850-5315Citrus/Hernando/Pasco
8373 Northcliffe Blvd.,Spring Hill, FL 34606
Phone: (352) 686-0213 Toll Free: 1-888-211-9921
Collier/Lee
6831 Palisades Park Ct., Suite 1 Ft. Myers, FL. 33912
Phone: (239) 210-4940 Toll Free: 1-888-272-2992
Hillsborough/Pinellas/Polk
5403 N. Church Ave, Tampa, FL 33614
Phone: (813) 506-6000 ext. 1200Ê Toll Free: 1-888-211-9918Ê
Indian River/ Martin/St.Lucie
1187 S. US Hwy. 1, Vero Beach, FL 32962
Phone: (772) 257-3100 Toll Free: 1-888-274-8575
Lake/Marion/Sumter/Volusia
2102 SW 20th Place, Building 200, Suite 201, Ocala, FL 34471
Phone: (352) 237-2351 Toll Free: 1-888-420-2539
