1. health and fitness

Issue
No 1
Care1st Health Plan
Spring 2 0 14
Newsletter
Exercising
Your Right to a
Second Opinion
You Have the Right to Request
a Second Opinion
The Benefits of
Breastfeeding
A Healthy Choice for
Babies and Mothers
Medi-Cal
Fraud,
Waste &
Abuse
We Speak
Your Language
The Importance of Communication
How to Take
Charge of
Your Health
Staying healthy on your
own can be a challenge
Accessing Services
Out of Our Network
Emergency & Urgent Care
Getting to
Know Your
Health Plan
Getting to Know
Your Health Plan
You can visit
our website at
www.care1st.com,
to learn more
about the
following topics:
01
Quality Improvement
Program and Annual
Achievements
At Care1st Health Plan, our goal is to
help you live a healthy life. That’s why
we offer so many ways for you to get
the information you need. In the list
below, we’ll explore some of the more
important things you should know.
For benefits information, be sure to
check your Member Handbook.
02
Disease Management
and Quality Improvement
Programs available
to members
03
Member Rights and
Responsibilities
04
Protected health
information also known as
Notice of Privacy Practices
05
Medication Formulary,
Pharmacy Management
Procedures and Patient
Safety
A hard copy of any of this information
is available upon request by contacting
Member Services at 1-800-605-2556.
Information on
Incentive Use
Rights and
Responsibilities
Care1st wants to make
sure there is appropriate
use of your benefits
and services, and we
discourage under-using
them. Care1st does not
reward doctors or staff for
keeping members from
getting care.
You can access your
Member Rights and
Responsibilities (Bill of
Rights) on our website
at www.care1st.com.
Also on the website,
we have the Rights
and Responsibilities
Statement available in
our 10 target languages.
When Care1st Health Plan
makes any changes to
the Members’ Rights and
Responsibilities, we will
also inform you by mail as
soon as possible. We will
also report changes in our
member newsletter.
Our Provider
Directory is for You
You play an important role in the
quality of care that you receive. Be
sure to choose a doctor that you
feel comfortable with and who helps
you to understand your healthcare
needs. If you would like a printed
copy of our Provider or Hospital
Directory, please call Care1st’s
Member Services at 1-800-605-2556.
Getting Preventive
Care is Important
To help protect your health, prevent
diseases and improve your quality
of life, Care1st wants you to
get checkups, preventive health
screenings and immunizations (shots)
that you need. To learn what preventive
services you and your family should
get, visit the Health Education section
of our website at www.care1st.com/
ca/members/health-education.asp.
If you would like a hard copy of
Preventive Health Guidelines,
please contact Care1st’s Member
Services at 1-800-605-2556.
Do you need help with Utilization
Management Services?
• Staff can help you during normal
business hours regarding UM
issues like, getting an authorization
or talking about denial of services.
Simply call us and we can help you
at 1-800-468-9935.
• Help you with TDD/TYY services
• Getting Language Assistance
for UM issues
Other Important
Information on
Our Website
Access to
Care Standards
(primary care, specialist
and behavioral health)
Language Help
Grievance Process
Appeal Process
Professional
Qualifications
(Providers)
Communication
Services (how to access
staff to discuss utilization
management issues)
Women’s Health
Services
Did you know that
members have direct
access to women’s
health specialists
for routine and
preventive care
without getting
prior authorization?
Some examples of
preventive health
care services are:
breast exams,
mammograms, and
well woman exams.
Confidentiality: What are my privacy rights?
It is important to know how Care1st protects your healthcare
information. This is also known as our Notice of Privacy Practices. If
you need a hard copy, contact Member Services at 1-800-605-2556.
in
this
issue
02
Getting to
Know Your
Health Plan
04
How to Take
Charge of Your
Health
05
Accessing
Services Out of
Our Network
06
Exercising
Your Right to a
Second Opinion
07
We Speak Your
Language
08
The Benefits of
Breastfeeding
10
Medi-Cal Fraud,
Waste & Abuse
H ow t o
Take Charge
of Your HEalth
Staying healthy on your own can be a challenge. That’s where
your doctor comes in. He or she is your partner in healthy living
and maintaining your wellness. Even when you are not at your
doctor’s office, your doctor can help by giving you free information
on many common health topics. You can refer to these when
you’re at home and use them to guide your healthy lifestyle.
If you would like any of these informational
materials,just ask your doctor or call Care1st.
You can also get useful, free health information
by visiting our website at www.care1st.com.
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Accessing
Services Out of
Our Network
In most cases, you will be able to
receive all needed general medicine
and specialty care within the Care1st
Health Plan network of doctors,
hospitals and specialists.
Living Well
Information Line
We offer an information line to answer
your questions about cholesterol, weight
management, exercise, nutrition and
diabetes. Please call Care1st’s Member
Services and ask to speak with Linda
Fleischman or Rosa Hernández.
However, there are certain cases
when you will be able to receive
emergency and urgent care services
from out-of-network providers.
Emergency & Urgent Care
If you are in the United States, but
outside of your service area, and you
have an urgent medical condition
requiring emergency or urgent care
services, you may go to the nearest
hospital or urgent care center for
treatment. Emergency services do
not require a referral or approval
from Care1st or your doctor.
Outside the U.S.
Free Weight
Management Classes
To help you and your family stay healthy,
we offer adult, teen and child weight
management classes. We offer these
classes at our resource center in
Huntington Park, California. To find out
when the next series begins, please call
Care1st’s Member Services.
Also, if you are in Mexico or Canada
and need urgent health services,
you may visit the nearest hospital or
urgent care facility. For more detailed
information about receiving out-ofnetwork care, please contact Care1st’s
Member Services department.
For more detailed
information
about receiving
out-of-network
care, please
contact Care1st’s
Member Services
department.
Exercising
Your Right to a
Second Opinion
Asking for a second opinion isn’t just one of those things they do
on TV shows and in movies. As a Care1st Health Plan member and
patient, you have the right to request a second opinion about a
diagnosis made by your personal care physician (PCP).
Many patients worry about making this request, but they shouldn’t be: doctors
are very comfortable with the request, and all good doctors understand your
desire to be well informed about your condition.
If you wish for a second opinion,
simply talk about it with your PCP,
specialist or Care1st’s Member
Services department. Your PCP,
specialist or Care1st will refer you
to a qualified healthcare professional
that can provide a second opinion.
If you request a second opinion from
your PCP, the second opinion will be
from another PCP of your choice from
the same physicians organization that
your PCP belongs to.
To set up a second opinion,
just call the doctor you
wish to see and make an
appointment after discussing
with your PCP. When at the
doctor’s office, show your
Care1st ID card just as you
would at your regular PCP or
specialist’s office.
If you request a second opinion about
a diagnosis that your specialist made,
the second opinion must come from
any independent physician association
(IPA) or medical group within our
network for the same specialty. If
there is no other qualified healthcare
professional within the network,
Care1st will authorize a second opinion
by a specialist outside of the network.
We Speak Your
Language
Care1st wants to make sure
that you can communicate
with your doctor and medical
staff in your language, including
American Sign Language.
Communication is an important
part of getting the most out of your
healthcare experience, which is why
we provide many resources to make
sure that you and your doctor are
communicating clearly.
If you need a free
interpreter for your next
doctor visit, please call
Care1st’s Member Services
Department at least 5-7
business days prior to your
appointment.
If your doctor does
not speak your
language, you
have the right to:
Ask Care1st or your
doctor for an interpreter
at no cost to you.
Receive interpreting
services 24 hours a day,
seven days per week.
This means interpreting
services are also
available to you after
normal business hours.
By law, your
doctor cannot:
Ask you to bring your
own interpreter or pay
for an interpreter.
Ask you to use your child
to interpret for you.
Refuse or delay medical
care services because
you do not speak English
or do not speak it well.
As a Care1st
member, you also
have the right to:
Get notices about
your benefits in
your language and
alternative format
(e.g., Braille, large print
and audio).
Get health education
brochures in your
language and
alternative format
(e.g., Braille, large print
and audio).
Be referred to
community agencies
that offer culturally
sensitive services.
File complaints and
grievances if we
do not meet your
language needs.
The
Benefits
of Breastfeeding
A Healthy Choice for
Babies and Mothers
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Did you know that over the past
10 years, the number of mothers
choosing to breastfeed their
children has been growing steadily?
Often called the “first food,” breast
milk is becoming the top choice
of nourishment for newborns and
infants everywhere. And as it turns
out, there are a lot of good health
benefits for both the mom and her
baby. Here are just a few of them:
Why breast milk is go od for your baby
RIENT
EA
Y
TO DIG
PR
OTECT
ST
It contains all the
nutrients your baby needs
S
E
UT
S
N
It is easy for the
baby to digest
It helps to protect
your baby from
many illnesses
Why breast milk is good for the mother
C OV ER
M
S AV
B
ON
DIN
G
ME
It helps you recover
from giving birth
ONEY &
TI
E
RE
It saves you money
and time
It gives you more chances
to spend time and bond
with your baby
If you need help getting started breastfeeding, be sure to talk to
your doctor. You can also call Women, Infants and Children (WIC)
at 1-888-942-2229. It’s free to call, so do it today.
Spring 2 0 1 4 Newslet t er - Page 9
Medi-Cal Fraud, Waste & Abuse
Abuse and fraud of Medi-Cal resources are the leading
causes of the rising costs of healthcare—costs that
affect patients, insurers and providers alike.
01
02
03
Falsifying
credentials
Upcoding charges and
unbundling services
Falsifying medical
exemptions
04
05
06
Conducting improper
enrollment/
disenrollment practices
Accepting kickbacks for
referring sicker patients
to specialists
Use of telemarketing/
selling as marketing
tools
07
08
Billing fee-for-service
(FFS) for capitated
services
Some Common
Examples of
Fraud Include
Engaging in
under-utilization
09
10
11
Double-billing for
healthcare services
or goods
Attracting healthy
patients or refusing
sicker patients
Persuading sicker
patients to disenroll
12
13
14
Billing for “phantom
patients” or services/
supplies not provided
Regularly denying
treatment requests
and specialist referrals
without regard to proper
medical evaluation
Concealing ownership
in a related company
without regard to proper
medical evaluation
Spr in g 2014 New sle tte r - Pa g e 10
!
Furthermore, fraud may be carried
out against individuals on Medi-Cal by
scammers looking to take advantage of
them. You can help protect yourself by
being able to identify and avoid crooks
and con artists.
If you suspect that fraud, waste or abuse
is taking place, you can report it today by
calling the Department of Health Services’
Anti-Fraud hotline: 1-800-822-6222.
Look Out
for Suspicious
Activity
Individuals going
door to door “selling”
healthcare items or
services (only your
doctor knows what
you need)
Callers asking you
for your Medi-Cal or
health plan number—
never give this
information away!
People offering
you money or
other incentives for
healthcare services
you don’t need
Always Keep
Your Identity
Secure
Do not give your
Social Security,
Medi-Cal, health
plan or banking
information to
someone you don’t
know or trust
Always carefully
review your plan
statement to make
sure all information
is correct
601 Potrero Grande Drive
Monterey Park, CA 91755
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