Questions About Your Benefits? Look inside for answers. 5 Reasons to Go Outdoors Try the natural way to lower stress. Prediabetes Reduce your risk

Transcription

1 SPRING 2017 SIMPLE SALMON Light up the grill! THE DASH DIET A delicious way to help lower blood pressure Questions About Your Benefits? Look inside for answers 5 Reasons to Go Outdoors Try the natural way to lower stress Prediabetes Reduce your risk twitter.com/tuftshealthplan facebook.com/tuftshealthplan

2 FROM THE PRESIDENT & CEO To Your Health! Warmer weather s here at last! Take advantage of it to renew your sense of wellbeing. Learn how spending time outdoors boosts your health on Share your thoughts page 6. Read about about this issue of Well! the DASH diet on page feedback@well.com 5, then stock up on summer produce to do something good for your heart and also help prevent conditions that can lead to prediabetes (see page 7). Inside you ll also find important information that will help you get the most out of your health care plan. Enjoy the season, and thank you for being a Tufts Health Plan member. Notice to Our Members Tufts Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. You can download a copy of our nondiscrimination policy at tuftshealthplan.com/ nondiscrimination. We provide free translation services to people whose primary language is not English. For help with translation services, call a member service representative at the number on your member ID card and ask for a translator. Thomas A. Croswell President & CEO 3 Is It Preventive or Diagnostic? Know the difference between these types of services. 4 HSA vs HRA Health savings accounts and health reimbursement arrangements compared. 4 Words You Should Know Defining copay and other terms. 5 The DASH Diet The DASH diet features delicious meals that turn out to be good for your heart. 6 A Natural Health Boost Five reasons to enjoy time outside. 7 The Lowdown on Prediabetes Who is at risk, and how to prevent it. 8 Check Your Benefits Online Find the plan details you need anytime, anywhere. 9 Get Money Back A guide to reimbursement for your expenses. 10 When You Have Questions You can ask us about a decision we ve made about your health care. 11 Access to Quality Care How we help you get the care you need. Well! is published once a year by Tufts Associated Health Maintenance Organization, Inc., 705 Mount Auburn Street, Watertown, MA Copyright 2017 by Tufts Associated Health Maintenance Organization, Inc. (Tufts Health Plan), Watertown, MA USA. All rights reserved. Materials in this issue may not be reproduced in whole or in part without written permission from Tufts Health Plan. All articles in this magazine are written and edited by experienced professionals in health care communications and are carefully reviewed by appropriate specialists before publication. This magazine, however, is not meant to replace professional medical advice or service. Well! does not promote any form of medical treatment, nor does it encourage selfmanagement of medical problems. Personal health problems should be brought to the attention of physicians and appropriate health professionals. Always consult your health care provider regarding any health or medical condition and before beginning any new treatment, exercise, or nutrition regimen. 2 tuftshealthplan.com

3 Is It Preventive or Diagnostic? Coverage may vary depending on what type of care you receive Preventive care and diagnostic services help us stay well, but the two terms can be confusing. Be sure to ask your provider why a service is necessary. PREVENTIVE Getting preventive care is one of the best ways to keep you and your family healthy. This includes yearly checkups, well baby visits, screenings, and immunizations. You typically pay no extra cost when you see an in-network provider for preventive care. Visit tuftshealthplan.com/screenings to learn more about the recommended schedule for adult preventive health screenings. DIAGNOSTIC When you have new symptoms or changes to a health condition, you need diagnostic care to find the cause. You may need to share some of the costs, such as a copay, co-insurance, or deductible. (See page 4 for definitions of these terms.) If you have questions about what your plan covers, please call the number on your member ID card or visit tuftshealthplan.com for more information. WHAT TYPE OF CARE IS IT? IT S PREVENTIVE IF The office visit is your routine wellness visit You have risk factors for diabetes so your doctor orders a routine diabetes blood test You have a routine screening for breast cancer OFFICE VISIT BLOOD TEST MAMMOGRAM IT S DIAGNOSTIC IF You have a cough or other symptom that won t go away You show symptoms that may be caused by diabetes so your doctor orders a diabetes blood test You notice a lump and get a mammogram so your doctor can evaluate it Preventive Services Usually Covered Routine physical exams Well baby and well child care visits Immunizations Breast cancer screening, including mammogram Blood pressure screening Cervical cancer screening Cholesterol screening Colorectal cancer screening, including colonoscopy Glucose (blood sugar) screening Eye exam A NOTE ABOUT COVERAGE: On plans that cover preventive services without cost share, in order to be covered in full, preventive care must be received from a doctor or health care provider in the Tufts Health Plan network. Only certain services qualify as preventive. To learn more, go to tuftshealthplan.com/preventivecare. SPRING 2017 Well! 3

4 HSA vs HRA Use this tip sheet to know key points of these two types of medical savings accounts Who Can Sign Up HEALTH SAVINGS ACCOUNT Think of an HSA as a medical bank account you can use with your health plan to pay for eligible health care expenses. Anyone covered by a highdeductible plan Who Owns It You Employer Who Can Put Money into It Is the Money Taxed? What Can I Spend It On? What Happens to Unused Money Your employer or you or both Annual contributions limited No. Contributions are made to your account tax-free. Out-of-pocket expenses including deductible, copays, and coinsurance Qualified medical expenses (dental, vision, prescription drugs) Health insurance premiums while collecting unemployment Funds roll over to the next year. HEALTH REIMBURSEMENT ARRANGEMENT Think of an HRA as a medical bank account your employer sets up that you can use to pay for eligible health care expenses. Anyone participating in a THP HMO or PPO plan and whose employer offers it Employer only No limit to contributions No. Employer contribution does not count as income. Depends on employer but usually can apply to most health care expenses, including deductible, copays, and coinsurance. May include expenses not covered by plan, such as acupuncture or chiropractic visits. Funds may or may not roll over, depending on employer arrangement. Insurance Terms You Need to Know OUT-OF-POCKET Some health care services are not covered by your benefits. These are called out-of-pocket expenses. You may have an out-of-pocket maximum, which is the most you will have to pay for covered services in a plan year. After you meet your outof-pocket maximum, your health plan will pay for 100 percent of covered medical expenses. DEDUCTIBLE Your deductible is the amount you must pay for health care services before your plan begins to pay for them. For example, if your annual deductible on your individual plan is $2,000, you pay the first $2,000 for any covered services. After that, your plan covers the cost. Your plan may cover some services, like a preventive checkup, before you reach your deductible. COPAYMENT A copay is a fixed amount ($20, for example) you pay for a covered health care service after you ve met your deductible. Let s say your plan s allowable cost for a doctor s visit is $100. Your copayment would be $20. COINSURANCE Coinsurance is a percentage of the fee for a service, depending on your plan. Let s say that your coinsurance for hospital care is 10 percent and your hospital bill costs $1,000. You pay $100 out of pocket (10 percent of the bill), and your plan pays the remaining $ tuftshealthplan.com

5 Simple Grilled Salmon INGREDIENTS ¼ cup olive oil ¼ cup low-sodium soy sauce 1 clove garlic, chopped fine 1 tsp grated fresh ginger 1 lime 4 (6 oz) salmon fillets DIRECTIONS 1. Whisk together oil, soy sauce, garlic, ginger, and juice of lime in a small bowl. 2. Pour marinade into a resealable plastic bag. Add fish, coat with marinade, squeeze out air, and seal bag. Place in refrigerator for 1 hour. 3. Clean and lightly oil the grate of an outdoor grill. Preheat grill to medium. 4. Remove salmon from bag, drain off excess marinade, and set fish on grill. (Discard unused marinade.) Grill fish for 5 minutes, flip gently, and grill 5 minutes more, or until fish begins to flake. Remove from heat and serve with brown rice and steamed broccoli. Serves: 4 Per serving: 430 calories, 10 g fat, 3 g saturated fat, 30 g carbs, 1 g fiber, 8 g protein, 210 mg sodium No Grill? Preheat oven to 450. Heat a lightly oiled grill pan over low for 1 minute. Raise heat to medium-high. Add fish to pan and cook about 4 minutes. Turn fish over and cook 2 minutes more. Transfer fish to oven. Cook 4 minutes more, or until fish is cooked through. Or: Heat a large cast-iron or stainless steel skillet over medium heat. Let pan warm up for at least a minute. Add 1 Tbsp of oil to coat bottom of pan. Add fish to pan and cook 4 minutes, flip, and cook about 4 minutes more, or until fish is cooked through. Eat to Lower Blood Pressure Try the DASH diet, designed to improve heart health with delicious meals What if you could lower your blood pressure by eating good foods instead of taking medication? That s the goal of the DASH diet (DASH stands for Dietary Approaches to Stop Hypertension). Developed by scientists at the National Institutes of Health, the plan has also turned out to be an effective way for some people to lose weight. Instead of strictly counting calories, you focus on eating a variety of foods that tend to be rich in nutrients that help lower blood pressure. The plan does require you to limit salt and cut back on processed foods, but no food groups are out of bounds. Two phases of DASH Phase 1, which lasts for the first 2 weeks, is designed to reset your metabolism. You cut back on carbohydrates, but stay full by eating plenty of heart-healthy foods. In Phase 2, or for as long as you re on the plan, you include carbs like whole grains, fruits, and higher-starch vegetables in your meals. Most people who follow the plan continue to lose weight, but at a slower rate than during the first phase. DASH for Health The DASH for Health program is an online program dedicated to helping you eat better, exercise better, and lose weight. With customized meal plans to help you get started, twice-weekly tips, tracking tools for weight, food, and exercise, and hundreds of recipes, you will eat better, feel better, and improve your health all while eating the foods you love. Tufts Health Plan members can sign up for the DASH for Health program for $34.50 for a 6-month subscription (50% off the regular subscription rate). To take advantage of this special offer, go to tuftshealthplan.dashforhealth.com and enter coupon code THP. SPRING 2017 Well! 5

6 Boost Your Health with Nature Five reasons to enjoy time in the great outdoors Spending time in nature offers more than a chance to enjoy beautiful scenery. Research shows the great outdoors may also offer health benefits. Take advantage of the good weather to get some fresh air as well as these rewards that boost your well-being. FEEL LESS STRESSED That relaxed feeling that goes with a walk in the woods is partially due to the fact that being out in nature lowers your levels of adrenaline and the hormone cortisol. Both are indicators of stress. Being out in the woods can also lower your heart rate, studies show. Researchers in Japan who analyzed the effects of nature on health call it forest therapy. BE MORE ACTIVE It s no surprise people tend to engage in physical activity like hiking or playing sports when they visit a park or recreation area. Even better, studies show that we engage in moderate to high levels of activity for longer than usual while there. HAVE MORE MENTAL ENERGY The Big Beautiful Gym Outside A week of too much work or too little sleep can result in that foggy feeling known as mental fatigue. Treating yourself to some nature time can restore your levels of mental energy and boost your sense of well-being. As New Englanders, we have a wonderful fitness center right beyond our doors. Mountains to climb, hills to hike, lakes and an ocean to swim, trails to bike and walk. Whether you re into hardcore workouts or strolling, there are plenty of places to enjoy your favorite outdoor activity or even try a new one. GET A BETTER WORKOUT From Alewife to Wompatuck, Massachusetts state parks offer hiking and biking trails, swimming, rock climbing, birding, golfing, and much more. Visit mass.gov/massparks to start. Boston has hundreds of parks, playgrounds, and sports courts for outdoor recreation. See boston.gov/departments/parks-and-recreation. Walking in the woods often means chances to climb up and down hills and scramble over rocks. Look for opportunities to make your walk more of a workout by increasing calorie burn and building muscle. BE FREE FROM SCREENS Surveys show kids are spending up to 6 hours a day looking at electronic screens. For adults who work at a computer, it s even worse. Give your eyes a break! Go out and marvel at a beautiful scene of natural beauty instead of looking at a photo of one on a screen. If you must take your phone in case of emergency, turn it off and stash it in a purse or pack. 6 tuftshealthplan.com Rhode Island is home to the Acadia Management Area, 14,000 acres of green space and many miles of trails, plus waterways for canoeing. Start exploring at riparks.com. If you want a hike with great views, head to Mount Monadnock in southern New Hampshire. Go to nhstateparks.org to match location with activity, like hiking, kayaking, or just walking in the woods.

7 Prediabetes: What You Should Know Who is at risk, and ways to keep it from becoming diabetes The Centers for Disease Control and Prevention estimates that 86 million Americans have prediabetes. To learn more, we turned to Anastassios Pittas, M.D., professor of medicine at Tufts University. Dr. Pittas shared these key facts about prediabetes. It s not really a disease If your doctor tells you that you have prediabetes, it means your blood glucose level is higher than normal but not high enough to be diagnosed as type 2 diabetes. Prediabetes itself is not a disease. It means you are at risk for having diabetes. Who is at risk? People with prediabetes tend to be overweight, not physically active, older, and have a family history of diabetes, or had diabetes during pregnancy. But none of these factors means that you will necessarily develop prediabetes. Are there symptoms? There are no signs or symptoms that most people could detect themselves. You need a blood test to know if your glucose levels are higher than they should be. If overweight and physically inactive, you might benefit from being screened for prediabetes. Talk to your doctor if concerned. What can someone do to lower the risk of having diabetes? The most important thing is to lose weight if you are overweight. It s usually recommended that someone lose at least 5 to 7 percent of their weight, but even losing 10 to 15 pounds can help. If you find it hard to eat less, at least change the quality of your diet. Try to stay away from foods with a high-glycemic load, like white bread, white rice, and russet potatoes. They raise your blood glucose more than other foods do. Avoid trans fats and limit red meat. Aim for a total of at least 30 minutes of physical activity every day. Prediabetes does not always become diabetes If you have prediabetes, you will not automatically develop diabetes. For most people, losing weight if necessary, eating well, and exercising regularly can return blood glucose to healthy levels. Breast Reconstruction Is Covered Under the Women s Health and Cancer Rights Act of 1998, you are covered for the following treatments related to a mastectomy: Reconstruction of the involved breast All stages of surgery and reconstruction of the other breast, with the goal of giving balanced appearance A prosthesis or artificial replacement Care for complications and physical problems of all stages of mastectomy, including lymphedema For more information about covered services, please call the number on your member ID card. Appointment Time? One way to stay well is to have a checkup as recommended by your primary care provider (PCP). Have you seen your PCP lately? Call your doctor s office soon to find out if it s time to schedule an appointment. SPRING 2017 Well! 7

8 NEWS FROM TUFTS HEALTH PLAN Check Your Benefits & Member Handbook Online You have many resources to help you understand your Tufts Health Plan coverage and benefits At mytuftshealthplan.com, you can check your benefits and coverage through your secure online account. Your Member Handbook can also help answer many questions you may have about your coverage, and give you information such as: A general description of your plan s benefits and services The types of payments you may make for covered services, including copayments, deductibles, and coinsurance How to get the care you need, and how your coverage may change if you get care outside your plan s service area, or from doctors and other providers not in our network What s in your Summary of Benefits and Coverage (SBC). To access your SBC, log in to tuftshealthplan.com/sbc and enter your company code and name. If you do not have your company code, contact Member Services. When and how to get emergency care How you can learn about providers in our network How to learn about your rights and responsibilities as a plan member How we review new treatments, instruments, or tools as well as new uses for them before we decide how to cover them How to get care from PCPs, specialists, and mental health care providers, as well as hospital services How to get care when your doctor s office is closed How you can tell us your complaints and ask for a review of decisions we may make about your benefits, your relationship to Tufts Health Plan, or how we will cover services How we manage the drugs we cover How you can submit a bill or ask for money back for out-of-pocket payments you make for covered services How you can get help if you need a translator How to Get a Copy of Your Handbook and SBC Read or print your Member Handbook (HMO, EPO, PPO and POS plans): Visit tuftshealthplan.com/member and click on Forms + Documents, then select your plan, and click on Handbooks. Get a copy mailed to you: Call a member service representative at the number on your member ID card. To check your coverage in detail: Save and read your SBC, a full description of your Tufts Health Plan coverage, which you get when you become a member. Please call a member service representative at the number on your member ID card for help in obtaining your SBC. 8 tuftshealthplan.com

9 NEWS FROM TUFTS HEALTH PLAN Get Money Back How to get reimbursed for your out-of-pocket expenses Perhaps you paid money out of your own pocket for emergency care you received while traveling outside the Tufts Health Plan service area. Or perhaps a covered dependent paid for urgent treatment at a clinic in another part of the country. Payments for health care: If you have paid out of pocket for covered health care services and you want to ask for reimbursement for expenses that exceed your applicable copayment, coinsurance, and/or deductible, fill out our Member Reimbursement Medical Claim Form and send it to us. We will pay you back for the out-of-pocket costs you paid that are covered under your plan, except for any copayments, coinsurance, and/or deductible you are responsible for. You can find the form at tuftshealthplan.com/member. Click on Forms + Documents, select your plan, and click on Member Forms where you ll find the Member Reimbursement Medical Claim Form. Prescription drug costs: If you re covered by the Tufts Health Plan prescription drug benefit and have paid for covered drugs, fill out and send the CVS Caremark claim form to the address listed on the form. You can find the form online at tuftshealthplan.com/member. Click Forms + Documents, select your plan, and click on Member Forms where you ll find the Prescription Reimbursement Standard Claim Form. If you have other prescription drug coverage, please check with the person in your company who manages health care benefits. You can also get medical and pharmacy reimbursement forms by calling a member service representative at the number on your member ID card. Three Things You Should Know 1There are deadlines for asking for your money back, so check your SBC, speak with the benefits manager where you work, or call a Tufts Health Plan member service representative at the number on your member ID card. 2If you paid for covered services you received from a doctor in our network, we will pay the doctor and ask the doctor to pay you. 3We pay out-of-network provider bills at what is called the reasonable charge. If the amount you paid is more than the reasonable charge not including any copayments, coinsurance, and deductible you paid you are responsible for paying the amount over the reasonable charge unless the services were for emergency care. SPRING 2017 Well! 9

10 NEWS FROM TUFTS HEALTH PLAN When You Have Questions or Concerns About Your Coverage As a Tufts Health Plan member, your input is important to us. There s a way you can ask questions or tell us your concerns about health care services or the coverage you get from Tufts Health Plan. There s also a way for you to ask for a review of a decision we have made about covering a health care service. Depending on the type of plan you are on, here is a guide letting you know where you can get answers to questions about your plan. If you don t know what kind of plan you are on, ask your employer or call a member service representative at the number on your member ID card. If you are covered under a Massachusetts fully insured plan You may be able to have certain decisions we have made reviewed by an external review agency designated by the Massachusetts Health Policy Commission (HPC) Office of Patient Protection (OPP) If you are a Rhode Island resident or you receive covered services in Rhode Island, you may be able to have certain decisions reviewed by an external review agency designated by the Rhode Island Department of Health (DOH), instead of through the OPP. If you are covered under a Rhode Island fully insured plan You may be able to have certain decisions we have made reviewed by an external review agency designated by the Rhode Island DOH. If you are covered under a selffunded plan Your self-funded plan may provide for an independent review of certain decisions by an external review agency. 10 tuftshealthplan.com About the review agencies The external review agencies designated by the Massachusetts OPP, the Rhode Island DOH, or your self-funded plan are independent organizations that check decisions your plan makes about covering health care services. The external review agencies are not connected in any way to Tufts Health Plan or your self-funded plan. To learn more about a review For more information about how to ask for a review of a decision we ve made about covering a health care service: Check your Summary of Benefits and Coverage (SBC). Call a member service representative at the number on your member ID card. Read more about how to do it in your Member Handbook. Members of HMO, EPO, PPO and POS plans can find it at tuftshealthplan.com/member. Click on Forms + Documents, select your plan, and click on Handbooks. Or ask a member service representative to send you a copy.

11 NEWS FROM TUFTS HEALTH PLAN Access to Quality Care Is Part of Our Plan We work hard to provide quality health care coverage for our members. Each year, we make a Quality Improvement Workplan to help us succeed. The plan is a set of goals and programs we believe will help the most members. To make our plan, we look at: Members concerns Medical and claims information Feedback we get from members and doctors Information about our members health The 2017 Quality Improvement Workplan focuses on topics including: Improving member service and satisfaction and increasing member understanding of how their plan works. Improving the Cultural and Linguistic needs of Tufts Health Plan s membership Encouraging and Supporting Continuity and Coordination Between Medical Care and Behavioral Health Care To learn more about the 2017 Quality Improvement Workplan and the progress we re making toward reaching our goals, call a member service representative at the number on your member ID card. Get More from Your Plan! Discover the convenience of mytuftshealthplan.com, the secure and easy way to better manage your health. Sign up today and you can: check your benefits see referrals and authorizations view a copy of your member ID card find updates on your claims Go to tuftshealthplan.com/commercialmembers to watch a video in order to learn more about mytuftshealthplan.com. To watch the Spanishlanguage version of the video, go to tuftshealthplan.com/miembroscomercial. How We Help You Get the Quality Care You Need Decisions are based on need, effectiveness How we review requests When we get requests, we review them based on up-todate medical standards and your Tufts Health Plan coverage. As part of the review, we decide if the health care service is medically: Necessary Appropriate Effective Who the reviewers are After a careful review, we decide about covering the service or treatment. Only qualified, licensed doctors or licensed psychologists, or pharmacists, when appropriate, make decisions to deny coverage for a service or treatment. We don t link compensation or reward reviewers to deny requests. Nor do we give financial incentives to encourage them to deny appropriate coverage or the under-use of health care services. We prohibit making decisions regarding hiring, promoting, or terminating employees based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. For more information about how we review requests to cover certain health care services, which we call utilization management, please read your SBC. SPRING 2017 Well! 11

12 705 Mount Auburn Street Watertown, MA LW-THP-Q217 In This Issue GET THE MOST out of your health care plan TIP SHEET: HSAs, HRAs, deductibles, and more PREDIABETES: Who s at risk and how to prevent it GRILLED SALMON for a heart-healthy meal PLUS How to get money back, manage your plan online, and find answers about your benefits