Health Plan Policy No. MKT Title: Page Count: 1 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated:

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1 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 1 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Scope This policy applies to all Tenet companies and subsidiaries that provide Health Insurance Marketplace (HIM) offerings. These companies and subsidiaries are referred to as the Health Plan hereafter. 2. Purpose The purpose of this communications plan is to establish policies and documented procedures to ensure that marketing and sales activities by the Health Plan are accurate and do not misrepresent the Health Plan s services. 3. Definitions Advertisements: Defined broadly to include materials/messages disseminated through a variety of media to prospects and consumers describing the Health Plan and its services. These aim to educate, inform and influence the specific audience. Consumer: A business or individual that purchases services from the Health Plan. Consumer: An individual person who is the direct or indirect recipient of the services of the Health Plan through an HIM plan. Contractor: A business entity that performs delegated functions on behalf of the Health Plan. Culture: The thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Delegation: The process by which an organization contracts with or otherwise arranges for another entity to perform functions and to assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate. Health Literacy: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions regarding their health. Licensed Agent: An individual who markets and/or sells products and includes internal sales force, brokers, agents, and all other individuals, entities, and downstream contractors who may be utilized to market and/or sell on behalf of the Health Plan. Misrepresentation means any of the following: Any untrue statement of a material fact; The making of any statement in such manner or order as to mislead a reasonably prudent person to a false conclusion of a material fact; o Any material misstatement of law; Any failure to disclose any matter required by law to be disclosed, including Any failure to make disclosure in accordance with the law. Staff: The Health Plan s employees, including full-time employees, part-time employees, and consultants. 1

2 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 2 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Policy Statement When advertising, marketing, promoting, or communicating its services, the Health Plan will: Comply with all applicable federal and state laws, including but not limited, to the Federal Trade Commission (FTC) truth in advertising standards; regulations regarding fraud and abuse and unfair trade practices; regulations regarding endorsements and testimonials; the U.S. Fair Debt Collection Practices Act, and securities laws; Abide by the Code of Advertising, Marketing, and Communications, which states: o o Materials must not be false, deceptive, unfair or disparaging, All direct or implied claims in any promotion must be truthful, not misleading in context, and founded on a reasonable basis that is already in existence and in hand before dissemination. This policy is inclusive of delegated activities, which will be subject to the same review and approval as materials developed by the plan. 5. Documented Procedures 5.1 Development, review and approval of communications plan This Health Plan communications plan policy and associated policies were reviewed and approved by the Policy Review and Approval Committee on 06/02/15 and will be reviewed and approved no less frequently than annually (every 12 months). 5.2 Prohibition of misrepresentation of Health Plan s services No marketing and sales materials shall be disseminated, and no marketing and sales activities shall be conducted by the Health Plan or its employees, agents or delegated entities that misrepresent the services of the organization. All such marketing and sales materials shall clearly and accurately communicate information about the Health Plan and its services. See Appendix A for examples of the Health Plan's web pages describing plan services. 5.3 Marketing and sales materials Marketing and sales materials, new and existing, shall accurately and clearly represent the Health Plan s services. Persons responsible for such materials shall follow the procedures in this policy to accomplish this objective. The plans must maintain records of marketing materials for 10 years as reasonably necessary for Health and Human Services (HHS) to conduct compliance reviews for Qualified Health Plans (QHPs) operating in Federally Facilitated Marketplaces (FFMs) Advertisements An ad must identify the entity responsible for it. The full licensed name of the insurer is required to be stated in each of its invitation-toinquire and to-contract ads, including the portion of the ad to be returned to the insurer or agent. The full licensed name must appear before the first appearance of any shortened or substituted name. An ad other than institutional may not use a trade name, group designation, name of parent company, service mark, etc. which without disclosing the name of the actual insurer would have the capacity and tendency to mislead or deceive a prospective purchaser as to the true identity of the insurer. 2

3 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 3 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: No ad may use a combination of words, symbols or physical materials which by their content, phrasing, shape, etc. are so similar to those of a federal or state government as to make it look like the ad is related to that government. An ad for an HMO must make that clear. An ad that contains an application and is advertising more than one policy must be presented so as to clearly reflect that the cost and benefits are applicable to separate policies of insurance. No ad may be used that, directly or by implication, has the capacity and tendency to mislead or deceive as to an insurer s assets, corporate structure, financial standing, age or relative position in the business. All information required to be disclosed must be set out conspicuously and in close conjunction with the statements to which the information relates or with appropriate captions of such prominence that required information is not minimized, rendered obscure, or presented in an ambiguous fashion, or intermingled with the context of the advertisement so as to be confusing or misleading. An ad may not directly or indirectly unfairly disparage competitors, their policies, services, or business methods, and may not unfairly disparage or minimize competing methods of marketing insurance Development process Marketing and sales materials are developed according to the following procedures: Marketing will call a meeting of all subject matter experts annually in June to begin the process of developing new materials and revising existing ones. Each attendee of the subject matter expert meeting will receive the template materials that were submitted to CMS and the applicable state department of insurance for certification (and recertification) as a QHP). Attendees of the subject matter expert meeting will be assigned to review the section of the templated materials that pertains to their department s work (e.g., Pharmacy) and will be given due dates to review and update (if necessary) these materials. The approved or updated materials will be submitted to Marketing by their due dates to enable Marketing employees or their designated entities to update/finalize mandated materials and create new sales materials. Marketing team members will check their materials against spreadsheets of state and federal requirements for each plan Review process Before any new or revised marketing and sales materials (including print, electronic, and the organization s website) are disseminated, they shall be reviewed by the process outlined below. This includes documents using standard templates, such as Summaries of Benefits and Coverage. This review will safeguard against misrepresentations about the Health Plan or its services, and specifically in regard to: The organization s benefit plans, Participating provider availability and accessibility, Plan coverage, including exclusions and limitations, 3

4 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 4 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Administrative requirements, and Medical management requirements. All advertising, marketing, and sales promotions are subject to interdepartmental review and approval by the following individuals before they can be published or distributed externally: A minimum of two Marketing employees includes author/updater and backup reviewer Subject matter expert(s) (and chain of command as appropriate) includes representatives from Member Services, Pharmacy, Network Services, Grievance and Appeals, Medical Services, Finance, Quality, Sales and Compliance; Consumer, provider or vendor if material includes references or claims about a consumer, provider or vendor, including use of trademarks Executive leadership vice president of sales, executive director of health plan operations, chief medical officer Compliance, as required Director of marketing Following approval by all individuals listed above, the director of marketing will perform a final review before any advertising, marketing, or sales promotional materials are sent for production and dissemination to consumers. Proof of review and approval of materials is shown by signing a review and approval sheet. See Appendix B for an example of the review/approval sheet. 5.4 Existing materials Periodically, and no less frequently than every 12 months, each piece of marketing and sales materials shall be reviewed under the process described in 5.3 above, to safeguard against misrepresentations about the Health Plan or its services. See the Provider Directory Policy, pp. 1, Section III. 6 Corrective Actions The Health Plan shall ensure that all problems of accuracy and clarity that are detected at any point, through the processes described in Section 5 above, shall be corrected as quickly as technically possible, given the nature of the error. Any such corrective action shall be reported immediately to the compliance department and to the quality management committee at its next meeting, and will include an analysis as to the cause of the problem. Problems are corrected and members are promptly notified of these corrections by mail and on the website. Website content and/or materials posted to the website that are found to contain errors or inaccuracies are immediately corrected and reposted. 6.1 Marketing and Sales Activities Marketing and sales activities shall accurately and clearly represent the Health Plan and its services. Persons responsible for such activities shall follow the procedures in this policy to accomplish this objective. Such activities will cover, at a minimum: The organization s benefit plans, Sales brokers and agents are trained on CMS and Texas Department of Insurance rules regarding accurate representation of plan benefits. They are also trained on plan benefits. See Appendix C, pp , for an example of training pertaining to plan benefits and p 11 for a training attendee sheet. See Summary of Benefits Coverage documents at Choice.com/SBCs or in Appendix F, pp. 83. See also Certificate of Coverage, pp for the plan coverage. Participating provider availability and accessibility, Sales brokers/agents are given access to the online provider directory, which is available on the Health Plan website. This tool can output a pdf of all contracted providers with information on provider location, contact numbers and showing those providers not taking new patients. See the example of a comprehensive provider directory in the documents Provider 4

5 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 5 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Directory_AllegianChoicePPO.pdf and_allegianchoicehmo.pdf. See also Snapshots of Allegian Choice Provider Directory. Plan coverage including exclusions and limitations. Plan coverage is included in the policy/certificate of insurance/evidence of coverage. Exclusions and limitations also are covered there (See pp ) and in Summaries of Benefits and Coverage (SBCs) and pharmacy riders. Sales brokers/agents and consumers can access SBCs through the Health Plan's website at See also Appendix F, pp Administrative requirements. These requirements are clearly spelled out in the policy/certificate of coverage/evidence of coverage. See pp and in the sample Certificate of Insurance. Medical management requirements. See pp of the sample Certificate of Insurance for utilization management requirements. The following sub-sections in state prohibited actions and describe training as well as oversight procedures meant to ensure information given to consumers is accurate and straightforward Prohibited activities Unapproved marketing activities The Health Plan prohibits marketing activities by a Licensed Agent that have not been approved by CMS, and/or the state department of insurance and the Health Plan. Examples of prohibited marketing activities by a Licensed Agent include, but are not limited to: Soliciting beneficiaries door-to-door Conducting a sales appointment, whether in person or on the phone, without prior consent from the prospect. The consent must be in writing or recorded prior to the sales appointment via a scope of appointment form or voice Recording Randomly knocking on the wrong door to solicit any additional leads or visit. Randomly slipping business cards or leave other marketing material under doors at a person s residence Sending unsolicited s to a prospect Obtaining lists for potential beneficiaries or acquiring addresses through any type of directory Reproducing, creating or distributing marketing or enrollment materials that are not CMS-, state- and Health Plan-approved Utilizing marketing or enrollment materials that are inappropriate for the enrollment period Making erroneous written or oral statements that conflict with the information contained in CMS approved materials Misleading, confusing or misrepresenting the coverage of Health Plan s Health Insurance Marketplace plans Gift or payments The Health Plan prohibits gifts or payments to induce enrollment or retain membership greater than $15 retail value and not to exceed an aggregate amount of $50 annually. The Health Plan does not offer payment to the potential enrollee. The Health Plan does not accept cash or checks from an enrollee. The Health Plan does not make a monthly plan premium, pay for enrollee s prescription drugs, or any co-payment or co-insurance for a potential enrollee or current member. The Health Plan does not offer gifts that have a retail purchase price of $15 or more. 5

6 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 6 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Face-to-face meetings The Licensed Agents cannot insist that a face-to-face meeting be required for a prospect to receive information about Health Plan Activities at educational meetings Prohibited activities by a Health Plan-employed Licensed Agent at educational health fairs include: Enrolling beneficiaries on site at educational health fairs and events Distributing CMS- and Health Plan-approved marketing materials that contain Health Planspecific plan benefit information Distributing Health Plan Licensed Agent s business cards Using providers or provider groups to distribute printed information comparing benefits of different health plans Accepting Health Plan Individual Election Forms in provider offices where health care is delivered Activities in health care settings Licensed Agents are prohibited from conducting sales presentations, distributing and accepting enrollment applications and soliciting beneficiaries in areas where patient s primary intent is to receive health care services, or are waiting to receive health care services. These restricted areas generally include, but are not limited to: Waiting rooms Exam rooms Hospital patient rooms Dialysis center treatment areas (where patients interact with their clinical team and receive treatment) Pharmacy areas (where patients interact with pharmacist providers and obtain medications). The prohibition against conducting marketing activities in health care settings extends to activities planned in health care settings outside of normal business hours. The Health Plan monitors marketing and presentation skills of Sales Agents Terminology and/or statements made while marketing Health Plan products Licensed Agents may not: o Misrepresent themselves, the plans, or the benefits and services covered by the plans. 6

7 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 7 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: o Claim within the marketing materials that they are recommended or endorsed by CMS, Medicare, State or the Department of Health & Human Services (DHHS). Section 1140 of the Social Security Act, 42 U.S.C. 1320b-10, prohibits the use of the department s name and logo, the agency s name and marks, and the word Medicare or Medicaid in a manner which would convey the false impression that such item is approved, endorsed, or authorized by CMS or DHHS, or that such person has some connection with, or authorization from, CMS or DHHS. o Use absolute superlatives (e.g., the best, highest ranked, rated number 1 ) unless they are substantiated with supporting data provided to CMS as a part of the marketing review process. o Compare the organization/plan(s) to another organization/plan(s) by name unless they have written concurrence from all plan sponsors being compared (for example, studies or statistical data as described in the CMS Marketing Guidelines). This documentation must be included when the material is submitted for review. Licensed Agents may: o State that the plan is approved for participation in Federal Exchange programs and/or that it is contracted to administer benefits Applications and enrollments Sales brokers and agents must avoid paper applications and help prospects use the online enrollment system whenever possible Sales commissions Sales commissions will not be paid on any enrollments made by a Licensed Agent who is not appropriately certified. Agents who are not appropriately certified and who enroll prospects will be terminated. Sales commissions will not be paid on any enrollments where a full presentation was not provided to the member Enrollment by unlicensed agents The Health Plan terminates upon discovery and reported incidences of submission of enrollments by unlicensed agents to the authority in the State and Health Plan Compliance department, where the application was submitted. The Health Plan will notify any clients that were enrolled in their plans by unqualified agents and advise those clients of the agent status. Clients may request to make a plan change (including a special election period) if applicable. 7

8 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 8 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Training of marketing and sales staff Agents and brokers must be licensed to sell insurance by the state(s) in which they work. Those who participate in the FFM for the individual market for the first time are required to complete a two-part registration process. Part I: Visit to complete: (See Appendix H for CMS page with links to training information.) o Required individual market training; and o Execution of the Agent Broker General Agreement and the Agent Broker Agreement for the FFM-Individual Market ( Privacy and o Security Agreement ). Part II: Visit the CMS Enterprise Portal: to complete: o Creation of an FFM user account; and o Identity proofing. Annually agents and brokers must complete a registration renewal process that includes completion of required training, and execution of the FFM Agreements. In addition to federal requirements, agents and brokers annually must complete a three- our training session to learn about the Health Plan offerings. See Appendix C pp for an example of a training presentation Oversight of marketing and sales staff representations To ensure the Health Plan and its Licensed Agents comply with Health Plan sales practices and all federal and state regulations, the Health Plan is implementing an agent oversight program as follows: The Health Plan shall monitor the skills of Licensed Agents for presentation conducted on behalf of the Health Plan. The skills assessments may be conducted in a training environment and/or by accompanying the licensed agent on sales presentations. Based on the results of the assessment, if further coaching skills and training are needed, the Sales Manager, or Field Marketing Organization (FMO) if applicable, will perform the needed training. When training is completed, the Sales Manager will conduct another skills assessment of the Licensed Agent. 6.2 Disclosure to consumers General availability of information At a minimum the Health Plan shall make the following information available to consumers and employer purchasers: 8

9 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 9 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: For whom English is not their primary language; and with special needs, such as cognitive or physical impairments. o Those who need information in other languages or formats (e.g., Braille) can obtain them by calling the Health Plan s Customer Service department. Translators also are available through Customer Service. The plan has a TTY line for those with a hearing impairment. SBCs include means for getting information in other languages (see Appendix F, pp. 89.). See also Allegian Welcome Letter and Obtain info in Spanish pdfs. o The website is written in plain language, and important information is highlighted List of providers that are in the provider network; o This information is available through the provider search tool found on the Health Plan website. Members can download and print out a complete listing of all providers for the plan. See the example of a comprehensive provider directory in the documents Provider Directory_AllegianChoicePPO.pdf and_allegianchoicehmo.pdf. See also Snapshots of Allegian Choice Provider Directory. Members or prospects may also contact the Health Plan Customer Service department to obtain a hard copy of the provider directory. Descriptions of participating provider compensation arrangements. o Upon the request of a member or a prospect, the Health Plan will make available the reimbursement methodology of contracted providers. The Participating Provider agrees to bill the Health Plan their usual and customary fee(s) for the services provided. The Plan will reimburse the lesser of the charges as billed or the fee maximum based on the then existing Allegian Choice Market Fee Schedule for Covered Services, less copayments, coinsurance and/or deductible amounts as applicable. Requests can be made by contacting the Health Plan Customer Service department. See Welcome Kit, pp for definitions of network providers and non-network providers. Tools the organization makes available to assist in self-managing care; The Health Plan provides a Healthy Living section on its website, which provides symptom checkers, information about medications, health and wellness information and other information that can help clients manage their care themselves. See Appendix D, pp. 80. We are currently developing a Healthy Living Trackers for clients. See for an example of a tracker developed for Medicare Advantage members. Consumer satisfaction statistics; o When the Health Plan gathers statistics through the methods discussed in Section 6.3 below, the Health Plan will post summaries of survey results to the Health Plan website and in the member newsletter. Administrative requirements; o The welcome kit sent to all new members includes specifics about paying premiums, how to submit grievances and appeals and other administrative requirements. (See the Welcome Kit, pp. 4, 8-17) Medical management requirements; o Information relating to medical management such as prior authorizations is available on the Health Plan website (See See also the Welcome Kit, pp. 5-6, 56, 84. How the health benefits program works; o The insurance policy/certificate of insurance/evidence of coverage, Summaries of Benefits Coverage and riders explain in detail how the benefits program works. (See these documents in Appendix F, pp and in the Welcome Kit, pp ) 9

10 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 10 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Financial responsibilities for consumers, including potential out-of-pocket costs such as deductibles, co-pays, co-insurance, annual and lifetime co-insurance limits, and changes that could occur during the enrollment period. o This information is found in the insurance policy/certificate of insurance/ evidence of coverage, which is mailed to new members. (See Welcome Kit, pp. 25, 35-42, It is also found in the Summaries of Benefit Coverage, which are located on See also Appendix F, pp for sample SBC.) Health benefits decision-making responsibilities for consumers; These responsibilities are found in the insurance policy/certificate of insurance/ evidence of coverage document, which is mailed to all new members. See Welcome Kit, pp. 25, 35-42, 48, Condition-specific criteria for benefits; These criteria, including those for conditions such as pregnancy and diabetes, are found in the insurance policy/certificate of insurance/evidence of coverage document, which is mailed to all new members. See the Welcome Kit, pp. 50, 64, 75. Coordination of benefits; Not applicable. See Attestation document. Descriptions of the processes that the organization uses to ensure compliance with regulatory health care parity requirements, including regulations pertaining to mental health and/or substance usage disorders (MHPAEA) if applicable. Before benefits are submitted to HHS/CMS, they are checked to ensure parity. The policy/certificate of insurance/evidence of coverage provides statements regarding mental health parity. See pp.71 in the Welcome Kit. Plan coverage including any exclusions and limitations. Plan coverage is contained in the insurance policy/certificate of insurance/evidence of coverage provided to each member upon enrollment. See pp of the Welcome Kit for exclusions and limitations. See also Appendix F, pp Information provided to consumers upon enrollment Upon a consumer s enrollment, the Health Plan shall provide the consumer with the following: Instructions on how to receive assistance via , telephone, or in person; This information in included in the welcome letter, on the website and in the policy/certificate of insurance/evidence of coverage. See Welcome Kit, pp.3, 4, 7, 12, 48, 95. The scope of covered benefits and general coverage guidelines; This information is included in the policy/certificate of insurance/evidence of coverage, Summary of Benefits and riders provided in the Welcome Kit. See pp of the Welcome Kit (esp. Section 4, pp ), Appendix F, pp Any obligations for consumers to cooperate with the organization's medical management programs; This includes the need to obtain prior authorization for certain medical procedures. See pp. 5-6 of the Welcome Kit for the Prior Auth list. How to access covered benefits, including: o Requirements for prior authorization; See pp. 5-6 of the Welcome Kit for the Prior Auth list. See also pp. 56 and 84 of the Welcome Kit. o Accessing emergency services and out-of-service-area services; See Appendix F (pp. 86) for an example of wording in the Summary of Benefit Coverage. o Ongoing access to current drug formulary; See Allegian Choice Formulary pdf and formulary link in the Welcome Kit, pp. 3.The most current formulary is found at o Ongoing access to an up-to-date provider directory; Clients are instructed to access the Health Plan s current provider directories by going online to the website or by contacting Customer Service to obtain a hard copy of the directory. See the provider directory (PPO and HMO) pulled using the online search tool. How to access information needed for effective financial decision-making, including: o Cost-sharing features under the benefits plan; See the SBC in Appendix F. pp o Specific benefits and coverage exclusions; See Welcome Kit, policy/certificate of coverage/evidence of coverage, Section 5, pp See also pp o Review of authorization processes necessary for coverage; See pp. 5-6 of the Welcome Kit for the Prior Auth list. See also pp. 56 and 84. o Seeking care once the consumer s personal health account or other health benefit resources have been exhausted; Clients may retain their policies as long as they pay their premium. See pp. 89 of Appendix F, SBC. 10

11 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 11 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: How to obtain the cost of covered benefits. Clients obtain this when shopping on our site for plan; their premium is also stated in the Welcome Kit letter. See Welcome Kit, pp.4, and Appendix F, SBC, pp Information and tips to assist in interactions, such as Financial decision-making" for health care. This information is provided through a CMS video posted on the Health Plan site's home page. See Screenshots of this video. See also Appendix D, pp , for an example of documents we provide to clients to help with decision-making. How to obtain prevention and wellness information. This information is found on the Health Plan website in the Healthy Living section. See Appendix D, pp. 80. See also the sample Healthy Living Tracker (HLT) pdf or visit How to obtain evidence-based health information and content for common conditions, diagnoses, and the treatment, diagnostics and interventions. This information is available via the Healthy Living tool, Healthwise, on the website, Clinical content is reviewed by the chief medical officer. See Appendix D, pp. 80. for the Healthwise site. Information on rights and responsibilities of members is found in the policy/certificate of insurance/ evidence of coverage. See the Welcome Kit (pp. 5-6, 8-17, 26-30) for examples of these. See also Appendix F, pp. 89, and COI, pp. 1-2, 8, 13, 16-17, 19, 44, 48-49, 57, Information on the importance of weighing cost/benefit information of selecting a health care treatment. This is explained in the CMS video accessible through the Health Plan website. See the Video Screenshots pdf and Appendix D (pp ) Complaint and appeals processes available to consumers. This is available in the policy/certificate of insurance/evidence of coverage. See pp. 8-17, 45, of the Welcome Kit. 6.3 Consumer input and surveys To better respond to the needs and wishes of its consumers, the Health Plan shall gather information about consumer satisfaction Gathering consumer information The methods for gathering such information shall include, at a minimum: Quality Rating System (QRS) The gathering of self-reported outcomes information from consumers; and The solicitation and response to consumers suggestions about how the Health Plan can best serve consumers QRS Consumer-reported outcomes information The Health Plan uses a certified QRS vendor to conduct the QRS survey annually. Consumerreported outcomes information in the form of grievance and quality of care concern data is reviewed quarterly at the Quality Management Committee Consumer suggestions Information received by Customer Service as well as case and disease management data are reviewed and used to develop interventions to enhance consumer satisfaction. In addition, the Contact Us page on the website invites consumers to send in their suggestions. Consumers enter and submit their suggestions through the Contact Us form. The suggestions are sent from the website via to the Customer Service department. Customer Service reroutes them to the Quality department. The Quality department reviews, records and tracks the suggestions, distributing them to subject matter experts for further review as needed. Suggestions deemed feasible by subject matter experts are reviewed by executive management, which then approves or disallows implementation of the suggestions. The Quality department contacts members whose suggestions are implemented to inform and thank them Analyzing consumer information 11

12 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 12 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: The information gathered from consumers under the methods described in above shall be analyzed to identify trends and opportunities and reported to the quality management committee no less frequently than annually. 6.4 Online Access Consumers will have online access to: Organization information; Healthcare information; and The ability to enroll in a health benefits plan. The content for the Health Plan website ( is developed, reviewed and approved with input from a committee of subject matter experts from departments such as Pharmacy and Medical Management and is also approved by executives, the Compliance department and the director of marketing. See Appendix B (pp. 5) for an example of a review and approval sheet. The Chief Medical Officer decides the websites to which the Health Plan website links based on their promotion and use of evidence-based practices and information. See the Links to Health Information Sites pdf. The website is reviewed at least quarterly for needed updates and improvements to the consumer experience Organization information The Health Plan gives consumers access to information about the Health Plan on the Home, About Us and Contact Us pages of the Health Plan website. Each web page also includes contact information for the Health Plan. See the sample About us Screen Shot and about us url screen shot Healthcare information At the time the site was launched (01/01/15), no general health information was found on the Health Plan website. A Healthy Living section is being developed for the website and will be reviewed by the Chief Medical Officer as described in Health and wellness information will be available through this section of the website (see Appendix D, pp. 80) Online enrollment Prospects may enroll by clicking on the Getting Started button on the home page of website. On this page, the prospect clicks the Quote button. The prospect can also receive information about subsidies and can compare plans. They can then decide to enroll immediately or come back later to finish enrollment. See the Allegian Choice Online Enrollment pdf for an example of this process. 6.5 Benefit Change Notification Consumers must be notified of changes in covered benefits prior to those changes taking effect. As the need for a benefit change is determined, the appropriate Health Plan department head contacts the Marketing department to request assistance with communications to members: Marketing drafts and/or reviews notification letter. To date, the Health Plan has not had to make changes to benefits. See the sample notification letter from a sister Health Plan, Appendix G pp. 95. Marketing assists with identifying printing and mailing resources. Marketing ensures the letters are mailed within 15 business days of being told of the change. Marketing posts notification of changes to the Health Plan website and includes notifications in newsletters as well. See Appendix G, pp. 96, for an example of a notification of benefits change letter. 6.6 Health Literacy The Health Plan addresses health literacy by using plain language in consumer materials, lowering the necessary cognitive effort required to use healthcare information and highlighting important information through the policy and procedures outlined in the Health Literacy Policy included in Appendix E, Sections IV and V (A), pp See also samples of materials in plain language in Appendix D, pp and Glossary of Health Terms in Appendix F (pp ). Our goals are to create materials in the sixth- to ninthgrade reading levels Training for staff members who interface with consumers 12

13 Health Plan Policy No. MKT Title: HEALTH INFORMATION MARKETPLACE COMMUNICATIONS PLAN ALLEGIAN HEALTH PLANS Page Count: 13 of 13 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: Customer Service staff members receive yearly training about the best ways to communicate with clients about complex medical topics. In addition, our Nurse Advice Line staffers are RNs trained to use plain language, short sentences and to fully explain technical terms Training for staff members who write content for consumers Marketing staff members receive training at least yearly regarding how to write in plain language, reduce reading levels and use graphics and callouts for highlighting key information for clients. They learn to use MS Word's tools for reading level, readability, avoidance of passive tense and jargon and in addition, to use Adobe Pro tools for measuring accessibility of documents. Training materials will be developed by June Promoting health literacy The Health Plan offers access through its website to a Healthy Living tool called Healthwise to promote learning about health conditions, symptoms of diseases and illnesses and prescription medications. In addition, the Health Plan offers health and wellness materials from Healthwise. Both the Healthwise site and materials are written in plain language at a fifth to sixth grade reading level. See Appendix D (pp ) for two examples of Healthwise documents and a screen capture of the Healthwise site, which demonstrate reading level and use of pictures. See also Appendix F, Glossary of Terms (pp ) Assessment of health literacy The Health Plan shall assess its health literacy efforts in the following ways: Assessment of plain language in documents Those who write consumer documents and web content self-monitor through use of readability and reading level tools in Word to ensure they comply with health literacy standards. Each person consults their copy of the Plain Language Thesaurus developed by the Centers for Disease Control (CDC). ( The director of Marketing performs final review of documents and web content to assess health literacy. The compliance department is responsible for auditing/reviewing materials to ensure compliance. Evaluation of success in achieving health literacy for consumers. Materials will be reviewed annually to ensure they meet standards for plain language, readability and ease of reading. In addition, consumers will be sent surveys to determine the level of difficulty in reading Health Plan materials. The Health Plan will also track numbers of calls related to difficulties consumers have in comprehending the plans materials and website. 7 Format for Presenting Benefit Information The Health Plan uses the standard templates for policies, Summaries of Benefits Coverage, and riders as defined by HHS/CMS. These documents are reviewed and approved according to the processes described in above and are written in plain language as described in Section 6.6 above. See Appendix E, pp for the Health Literacy Policy, Appendix E, pp See Appendix F for a sample Summary of Benefits Coverage and the Uniform Glossary of Terms (pp ). 8 Targeted Consumer Outreach Once HRA and claims data become available in sufficient quantities, the Health Plan will analyze this data to identify populations with specific conditions. Medical Management will send targeted postcards and letters to these populations to provide reminders about needed services, adherence to medications, education to assist with self-management of condition and follow-up information. The Marketing department will work with Medical Management to design, develop and disseminate postcards, flyers, and web content targeted to various populations on a quarterly basis and will include similar information in newsletters to clients at least two times per year. See Appendix G, pp. 96 for an example of an outreach letter written for clients with diabetes. Revision History Date Reason for Change 01/01/2016 Revision 01/01/2015 New Policy 13

14 APPENDICES 1

15 APPENDIX A The Allegian Choice website provides easy access to information about services. See the following web pages for examples. [Core 10 (a)] 2

16 APPENDIX A 3

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38 Advantage Health Care Management Company (AHCMC) Quoting and Enrollment Portal User Guide 11/01/

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94 Appendix E Health Plan Policy No. MKT Title: HEALTH LITERACY Page Count: 1 of 2 Effective Date: 01/01/16 Retires Policy Dated: Previous Versions Dated: I. SCOPE: This policy applies to (1) Tenet Healthcare Corporation and its wholly owned subsidiaries and affiliates (each, an Affiliate ); (2) any other entity or organization in which Tenet Healthcare Corporation or an Affiliate owns a direct or indirect equity interest greater than 50%; and (3) any hospital or healthcare facility in which an Affiliate either manages or controls the day-to-day operations of the facility (each, a Tenet Facility ) (collectively, Tenet ). II. PURPOSE: The purpose of this policy is to ensure health-related materials are available to all Health Plan clients. The Health Plan distributes informational, promotional and educational materials according to the client s specific illnesses, preventive care needs and other services they are eligible to receive. III. DEFINITIONS: Health Plan refers to the Tenet health plan that offers Health Insurance Marketplace plans. Health Literacy is defined as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate decisions regarding their health. Plain Language is defined as communication that uses short words and sentences, common terms instead of medical jargon, and focuses on essential information recipients need to understand. Health Promotional and Educational Materials may include but are not limited to letters, member newsletters, summaries of benefits, website content, books, handouts, pamphlets, and brochures. IV. POLICY: Health Plan departments, such as Marketing, Member Services, Medical Services, Pharmacy and Quality, develop or obtain health-related materials to distribute to all clients. The Health Plan supports Health Literacy by using plain language when communicating with members and in written communication to members, and by highlighting information of importance through use of bolding, side bars and graphics when appropriate. 81

95 APPENDIX E V. PROCEDURES: A. All consumer material/health education is written in plain language. This material is checked using the readability statistics included in Microsoft Word. The Health Plan distributes informational, promotional and educational materials according to the client s specific illnesses, preventive care needs and other services they are eligible to receive. B. When the percentage of non-english speakers exceeds five percent, the Health Plan provides consumer documents in the speakers native language. C. The Health Plan assesses clients needs for educational materials and provides the information to the clients. D. Clients may contact the Customer Service toll-free number with questions regarding their health and the materials they receive from the Health Plan. E. Responsible Person - The Health Plan s Compliance Department is responsible for ensuring that all personnel adhere to the requirements of this policy, that these procedures are implemented and followed at the Health Plan, and that instances of non-compliance with this policy are reported to the Chief Compliance Officer. F. Auditing and Monitoring - The Compliance Department will audit and monitor materials for compliance with this policy. G. Enforcement - All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such performance management may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law. 82

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