Fall 2014

Member Newsletter

MedStar Family Choice Receives Top Quality ScoresThe Maryland Department of Health and Mental Hygiene (DHMH) is required to evaluate the quality of care provided to Maryland medical assistance recipients enrolled in HealthChoice managed

care organizations. To ensure that the services provided to members meet established regulations, DHMH uses Delmarva Foundation for Medical Care Inc. (Delmarva) as an outside quality review agency to perform a systems performance review.

MedStar Family Choice continues to receive top scores for performance standards by Delmarva. MedStar Family Choice has received a score of 100 percent on their systems performance review in all areas.

This review looks at:

• Quality improvement (Exempt in 2013)

• Utilization review

• Governing body

• Outreach (Exempt in 2013)

• Health education (Exempt in 2013)

• Enrollee rights

• Fraud and abuse

• Oversight of delegated entities

• Credentialing and recredentialing

• Availability and accessibility

• Continuity of care

The calendar year 2013 Delmarva results review show that MedStar Family Choice:

• Continues to have a very focused Quality Improvement program

• Has a comprehensive and targeted outreach plan, which continues to be a strength of MedStar Family Choice

• Has a very detailed oversight process for it’s delegated vendors

• Has an effective working relationship with its substance abuse vendor to ensure coordination of care for members with substance abuse

• Has a very unique approach to assessing coordination of care between the members’ specialists and primary care providers

MedStar Family Choice will continue to focus on quality improvement efforts to improve the care provided to you and your family. In the next issue, look for information about the MedStar Family Choice HEDIS® scores.

Maryland HealthChoice Program

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Why Members Should Follow up With Their Primary Care Provider (PCP) After Emergency Room (ER), Urgent Care and MedStar PromptCare Visits Your primary care physician gets to know you over a period of time. They get a sense of the person you are. They can get to know your values, your family situation, your job pressures, and maybe even your goals. These may seem like unimportant pieces in relation to your health care, but they can all have a major impact on your health. Understanding these things may provide valuable information as they show what is troubling you. Following up with your primary care physician can help ensure you are healing correctly after your ER visit and on your way back to healthy living.

Another option for being treated quickly is MedStar PromptCare. These centers are meant to provide individuals with medical assistance for treating nonlife-threatening conditions that require attention immediately. These minor conditions can include flu, fever, cuts, sprains, insect bites, and mild fractures. These facilities offer extended hours and do not require an appointment.

More Reasons Why You Should Follow up With Your Primary Care Provider (PCP) After an ER, Urgent Care and MedStar PromptCare Visit• Healthcare professionals who are skilled in

the art of healing

• Your primary care physician will be able to guide you through maintaining, organizing, improving your health, and ultimately coordinate your health care.

• High-quality service and care you will receive

• Treats you regularly and should be involved with your health

• Can help educate you about your health

You should follow up with a primary care provider who can step back and look at the “big picture” of your health–especially during times when a diagnosis is needed. This is what primary care physicians are trained to do. Any set of symptoms can have a lot of possible explanations. A primary care physician has to have an open mind, listen carefully and consider all the possibilities.

Bottom line is … follow up with your primary care physician after an ER or urgent care visit.

Stay healthy!

Consult With Your Doctor Before You Change the Way You Take Medication It’s important to remember that before you decide to stop taking medication, you should talk with your doctor. You should also talk with your doctor before you make any changes to the way you’re taking the medication as well.

There are many factors to consider when making changes that could include risks to your health if you haven’t talked with a provider.

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Member Rights and ResponsibilitiesYou have the right to:

• Be treated with respect and dignity, no matter your race, color, creed, ancestry, marital status, political affiliation, national origin, age, sexual orientation, religion, gender, personal appearance, physical or mental disability, or type of illness or condition.

• Have access to care no matter your race, color, creed, ancestry, marital status, political affiliation, national origin, age, sexual orientation, religion, gender, personal appearance, physical or mental disability, or type of illness or condition.

• Privacy—your medical records and all information about your health is private and will only be shared in a manner that follows state and federal laws.

• Privacy during treatment

• Information—you may ask for information about MedStar Family Choice, its services, its doctors and other caregivers, and about your rights and responsibilities as a member of the health plan.

• Make recommendations regarding your rights and responsibilities as a member of MedStar Family Choice.

• Ask for the qualifications of the people treating you.

• Choose a primary care provider (PCP) from MedStar Family Choice’s listing of doctors.

• Be told what your health problem is, what treatment you will be given, and what risks are related to your illness and treatment. This must be told to you so that you understand the information.

• Talk to your doctor and help to make choices about your health care and treatments.

• Choose someone who will have the legal right to make healthcare choices for you if you become unable to tell your wishes yourself.

• Refuse any treatment by a provider, and be told what might happen if you don’t have the treatment.

• Discuss all of the appropriate or medically necessary treatment options, regardless of the cost or whether they are covered by your health plan. MedStar Family Choice does not restrict providers from discussing all of the appropriate or medically necessary treatment options with members.

• Develop advance directives or a living will.

• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

• Request and receive a copy of your medical records and request that they be amended or corrected as allowed.

• Exercise your rights and know that the exercise of those rights will not adversely affect the way that MedStar Family Choice or our providers treat you.

• File a complaint, appeal or grievance with us and have it resolved in a reasonable amount of time. For example, the complaint, appeal or grievance could include a concern about the care you received.

• File a complaint, appeal or grievance against MedStar Family Choice with the state.

• State fair hearings

• Request that ongoing benefits be continued during an appeal or state fair hearing; however, you may have to pay for the continued benefits if our decision is upheld in the appeal or hearing.

• Receive a second opinion from another doctor in MedStar Family Choice if you don’t agree with your doctor’s opinion about the services that you need. Contact us at 888-404-3549 for help with this.

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• Receive other information about us, such as how we are managed. You may request this information by calling 888-404-3549.

It is your responsibility to:

• Read the member handbook so that you can understand the services provided and how to contact MedStar Family Choice with questions.

• Be courteous and respectful to MedStar Family Choice staff, healthcare providers and office staff.

• Tell the truth about your health. You must tell about any illnesses you had before. You must tell about operations you had before. You must tell what medicines you use or have used in the past. You must tell MedStar Family Choice and your healthcare providers any information we may need in order to provide care to you.

• Do what your doctor tells you to do to get well or stay well. Follow the plans and instructions for your care that you and your healthcare provider have agreed to.

• Live a healthy lifestyle, which includes seeing your doctor regularly and following preventive care guidelines, such as screenings and immunizations.

• Accept what might happen to you if you refuse treatment or if you do not follow the advice given to you.

• Tell your doctor if your health changes in any way that you did not expect.

• Know the name of your primary care provider (PCP) and get your PCP’s okay before getting care from anyone else.

• Make appointments with your PCP during office hours instead of using the emergency room for things that are not emergencies.

• Be on time for all your appointments. Let the office know at least 24 hours ahead of time when you cannot keep an appointment.

• Carry your ID card and photo ID with you always. Tell the people in the doctor’s office, lab, drug store or anywhere that you are getting health care, that you are a MedStar Family Choice member.

• Ask questions about your care. Make sure that you understand what your health problem is, and that you understand your treatment and that you participate in developing treatment goals that both you and your doctor agree on.

• Notify MedStar Family Choice of any car accidents, falls, etc., where someone else may be at fault. You must work with MedStar Family Choice concerning the accident and the bills.

• Call Member Services toll-free at 888-404-3549 if you are having any problems getting the care you need.

• Notify MedStar Family Choice, the local health department and/or your DSS caseworker if you move.

• Complete your renewal applications in a timely manner to prevent gaps in your health insurance.

• Report any other health insurance coverage to your doctor and MedStar Family Choice.

• Give your doctor a copy of your living will and advance directive if you have one.

• Report any known or suspected fraud and abuse as it relates to benefits, services or payments. Please contact our Member Services department at 888-404-3549.

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What is Utilization Management?To make sure that our members get the health care they need, MedStar Family Choice follows a basic review process called utilization review.

A member’s doctor sends a request for services to MedStar Family Choice, usually by phone or fax. Our experienced clinical staff reviews all requests. MedStar Family Choice decisions are based on national criteria, such as Inter-Qual and Medicaid guidelines. Member needs that fall outside of standard criteria are reviewed by our physician staff to see if they are medically necessary.

MedStar Family Choice approves or denies services based upon whether the service is medically needed and a covered benefit. We do not financially reward our providers, staff or anyone contracted with MedStar Family Choice for denying services. In addition, we do not financially reward anyone involved in the decision process in such a way that would encourage less use of services.

MedStar Family Choice requires up to two business days to process a complete request for services. Requests are considered complete when the doctor sends the necessary medical information. The final decision cannot take longer than seven days, whether or not all clinical information has been received.

If MedStar Family Choice denies the request, the provider and the member will receive a copy of the denial. The letter will list instructions on how to appeal the decision. Members may also contact the HealthChoice Enrollee Helpline at 800-284-4510.

Did You Know, Your Doctor is Here to Help You With All Your Healthcare Needs?Your doctor or primary care provider (PCP) can manage much of your healthcare needs. You may not need a specialty referral in many cases. Your PCP has the best relationship with you or your child and knows your health history. Your doctor should be the first person to discuss any health concerns with you prior to giving you a referral to see a specialist.

It is important to follow up on all appointments that you have scheduled with your PCP. If there are any problems noted, your PCP can take care of it right away.

If you feel like you want a second opinion, you have the right to get one from another in-network provider or a specialist. Always talk openly and voice your opinion with your PCP, so you can make a decision together regarding the need to see a specialist, or the choice of letting your PCP handle your health concern.

Your Links to Good HealthYou can find valuable information about all of the healthcare benefits offered at MedStar Family Choice on our website.

If you are interested in additional information about MedStar Health hospitals, visit the websites:

MedStarHealth.com

MedStarFamilyChoice.com

If you do not have access to the Internet, you may call our Member Services department at 888-404-3549 for a listing of classes and other healthcare resources.

Acute BronchitisIt is cold and flu season again, and if you find yourself with a bad cough, you may have acute bronchitis, sometimes called a “chest cold.” The symptoms of acute bronchitis are cough (wet or dry), low grade fever, chest congestion, wheezing, and fatigue.

There are many myths about bronchitis:

If I have acute bronchitis, I need an antibiotic. FALSE

Many people feel that an antibiotic is needed to treat this condition, but this may not always be true. In fact, 90 percent of bronchitis cases are caused by viruses. A virus is not killed by antibiotics. Also, antibiotics can cause unpleasant side effects (allergic reactions, nausea, diarrhea, and yeast infections to name a just a few). So, the message is that antibiotics may not help you get over your cough and, in fact, may do you harm in some cases.

I am coughing up colored mucus; I must need an antibiotic. FALSE

This myth has been proven false by research. The color of mucus does NOT indicate a bacterial infection and does not mean an antibiotic would be helpful.

This cough has been going on for a week; I must need an antibiotic. FALSE

Again, this is not the case. The cough associated with bronchitis typically lasts for three weeks. Taking an antibiotic will not shorten the cough if the bronchitis infection is caused by a virus.

There are many times when an antibiotic is a good idea. If you have lung disease (asthma, COPD), heart disease or any other significant medical problem, it would be a good idea to see your doctor. Also, if you have been exposed to Pertussis (whooping cough), an antibiotic is a must. See your doctor if you have shortness of breath, wheezing, high fever (greater than 100.4), are coughing up blood, or are not getting any better after four weeks of cough or for ANY other issue that you find troublesome. Your doctor will help guide you in the right direction!

Please Join Our Consumer Advisory Board

Help us:

• Improve your health care.

• Understand and resolve member questions and issues.

• Make a difference in our members’ health care.

Meetings are held six times a year:

• Lunch is provided and you will get a gift certificate for attending.

• Transportation is provided if needed.

To find out more, call our Outreach staff at 800-905-1722.

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Free Interpreter Services AvailableIf you know a MedStar Family Choice member who does not speak English—or doesn’t speak it well—call Member Services toll free at 888-404-3549. We have interpreters to help members when visiting their doctors. We will also provide an interpreter to help nonEnglish- speaking members read written information sent by Member Services.

If you or someone you know is deaf or has trouble hearing, a TTY line is available. Just call 800-508-6975. In addition, members can access Maryland Relay for TTY assistance.

MedStar Family Choice also has people available who can use sign language to help you during doctor visits. You, or someone who can speak for you, must let the Member Services representative know that you need an interpreter.

Si necesita un interprete, por favor contacte al departamento de Servicio al Miembro al 888-404-3549.

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Did you know?We understand that some medical conditions make it hard for you to manage on your own.

We have nurses and social workers who can help you manage chronic illnesses, like diabetes, asthma, COPD, wounds, pain management, and even substance abuse.

We also have a nurse who can help you take care of yourself and your baby if you have a high-risk pregnancy.

MedStar Family Choice nurses and social workers are also here for you if you need a transplant, if you have many illnesses and need help coordinating your care, or if you have suffered an event that leaves you unable to care for yourself.

You can learn more about our Complex Case Management program and our Disease Management programs on our website at MedStarFamilyChoice.com or by calling 410-933-2200 (Option #1) to ask about joining a Case Management program.

8094 Sandpiper Circle, Suite O Baltimore, MD 21236 888-404-3549 PHONE

MedStarFamilyChoice.com

The MedStar Family Choice member newsletter is a publication of MedStar Family Choice.

Submit new items for the next issue to jonathan.everett@medstar.net.

Kenneth Samet MedStar Health President & CEO

Jonathan Everett Editor

Eric Wagner President, MedStar Family Choice

Patryce Toye, MD Medical Director

14-MFC-1749.102014

Here When You Need Us: 24/7 Nurse Advice LineMedStar Family Choice knows that a health problem can happen when you least expect it.

That’s why we offer a Nurse Advice Line for you 24 hours a day, seven days a week.

Just pick up the phone and call.

If you have an illness, injury or just a question about your health, our Nurse Advice Line can help you get the care you need—whenever you need it.

Call 855-210-6204 any time.

Contact us Any Time You Need HelpPlease contact MedStar Family Choice if you have any questions or concerns about the services we provide. The MedStar Family Choice staff is available Monday through Friday from 8:30 a.m. to 5 p.m. You can also call our Member Services department toll free at 888-404-3549, Monday through Friday, from 8:30 a.m. to 5 p.m.

Please call during normal business hours to have your issues addressed. You may leave us a nonurgent message after hours. Calls received after normal business hours will be returned the next business day.

Important Numbers to Know:

Care Management phone: 800-905-1722 or 410-933-2200

Case Management fax: 855-829-2209 or 410-933-2209

Utilization Management fax: 888-243-1790 or 410-933-2274

Outreach fax: 888-991-2232 or 410-933-2232

Member Services phone: 888-404-3549

Nurse Advice Line phone: 855-210-6204